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Glass RC &?/ 
Book_^ 7 3 $~6 






TREATISE 



ON THE 



DISEASES OF THE HEART, 



AND 



GREAT VESSELS. 



BY 

R. J. BERT1N, 

PROFESSOR OF HYGIENE TO THE FACULTY OF MEDICINE OF PARIS, CHEVALIER OF THE ROYAL 
ORDER OF THE LEGION OF HONOCR, PHYSICIAN IN CHIEF OF THE HOSPITAL CO- 
CHIN, &C, HONORARY MEMBER OF THE ROYAL ACADEMY OF MEDICINE. 



EDITED BY 

J. BOUILLAUD, 

DOCTOR IN MEDICINE OF THE FACULTY OF PARIS, FORMERLY RESIDENT PUPIL OF THE HOS- 
PITALS OF THAT CITY. 



Stattslatrti from the iFwwft, 

BY 

CHARLES W. CHAUNCY, M. D. 



PHILADELPHIA: 
CAREY, LEA & BLANCHARD. 

1833. 




/ess 



• •♦. 



'■' 









Entered, according* to the Act of Congress, in the year 1833, by Ca- 
rey, Lea. & Blanch ard, in the Clerk's Office of the District Court of 
the Eastern District of Pennsylvania. 



/A'? *r> 



GRIGGS & DICKINSON, HUNTERS, 






JAMES H. PIERREPONT, M. D v 

This Translation is respectfully inscribed as a 
memorial of that affability and kindness which have 
ever marked his attentions upon the sick; and as 
a testimony of respect for his superior discernment 
and skill in the discrimination and treatment of 

disease — 

By his early Friend and Pupil, 

Charles W. Chauncy, 
Portsmouth, JY. H, 



INTRODUCTION 

BY THE TRANSLATOR. 



The physician, like the divine, should he endowed 
with all knowledge, not all the knowledge of every 
science, but so much of it as to be able to understand 
the moral and physical phenomena which occur in 
man, in a state of disease ; hence we obtain a mirror, 
which reflects the diseased condition of the system 
or constitution exposed to our observation. 

Our actual knowledge of disease, then, consists of an 
interpretation of all the phenomena, moral, physical, 
and psychological, as they actually exist in the morbid 
state of the body. 

Such knowledge is acquired by directing our at- 
tention to those general principles of induction, ana- 
logy, association, and experience, which are found to 
be consistent with that great moral principle of truth 
which pervades the whole human family. 

Such knowledge includes especially the study of 



Vi INTRODUCTION. 

anatomy, physics, pathology, metaphysics, and the 
general or moral history of man, and may be greatly 
improved by experience and observation, and even 
perfected by attending to the topographical pheno- 
mena and organization of disease. 

The physician's general knowledge, then, cannot be 
too extensive; but his knowledge of disease must de- 
pend, for the most, part upon the accuracy with which 
he notes morbid phenomena, and traces their analogy 
with his previous observations and the eifects pro- 
duced after death. The pathological anatomy, then, 
of all the regions of the body should be the ultimate 
object of inquiry. With this view I have under- 
taken to supply, as far as I am able, the deficiencies 
in this particular department of American Medical 
Literature, by such translations from foreign works 
as portray the actual state of disease in the various 
regions of the body ; so that when the diseases of 
every part of the system have been studied, we shall 
be familiar with the morbid phenomena of every part, 
and the combinations of morbid phenomena which 
compose a complete body of medical anatomy. 

As the heart is the most central organ of the body, 
we think it would be most proper to begin with the 
study of the peculiar diseases of that organ ; for this 
purpose we have selected Bertin, as containing a 
more complete exposition of those diseases than any 
other work with which we are acquainted- unless 



INTRODUCTION. Vll 

it be Laennec, who is too critical and positive for re- 
ference respecting the actual progress of any parti- 
cular disease of that organ. In fact, it can scarcely 
be said that we are in possession of any complete and 
perfect history of the diseases of the heart. The 
French pathologists have prepared the way for a more 
thorough and satisfactory investigation of this class of 
diseases; and the plan devised by Bertin is, perhaps, 
better calculated to attain the object which has been 
proposed than any other. Corvisart was the first 
who understood the proper method of studying these 
diseases: the present author, however, was a pupil of 
Corvisart, and not only had the advantage of his dis- 
coveries, but of the generally improved state of me- 
dical science among his cotemporaries. Armstrong, 
Farr and Abercrombie, have done much in this de- 
partment of medical inquiry; but Cruveilhier, Lermi- 
nier, Andral, Louis and Bouillaud, have effected much 
more. Bertin deserves to be ranked in this class 
of authors. His classification is anatomically correct, 
and he has investigated the diseases of the appropri- 
ate textures of that organ so accurately, that it is 
hardly possible to conceive of a case for which we 
may not find a parallel in the present w r ork. 

It is somewhat singular that among the numerous 
translations and original works which have issued of 
late years from the American press, no work has as 
yet appeared which can justly be entitled to be con- 



Viil INTRODUCTION. 

sidered a monograph on these diseases, unless it be 
that portion of Laennec's work which treats of these 
diseases. A translation of Corvisart was published in 
Boston, in 1819; but that work, though valuable for oc- 
casional reference, has been nearly superseded by the 
sagacious remarks and criticisms of Laennec. Among 
the authors of the present day, who have given us in- 
formation on the subject, Burns has been the princi- 
pal author referred to for many years. His work, 
though highly meritorious for the physiological views 
it contains, has fallen considerably behind the im- 
proved state of medical pathology. Dr. Latham, of 
St. Bartholomew's Hospital, has published, in the 
London Medical Gazette, the substance of some high- 
ly interesting lectures which he delivered before the 
College of Physicians, and Mr. Hope has lately pub- 
lished some exceedingly valuable essays on the sub- 
ject; but there is no work, on the whole, more justly 
entitled to rank as classic, than Bertin's. It is only 
necessary to dip into that part of Laennec's work 
which treats of the diseases of the heart, to estimate 
satisfactorily the repute and favour which that great 
physician uniformly entertained for the writings of 
Bertin. These two philosophers have differed on 
some of the nicer points of pathological inquiry, which 
gives more interest to their speculations, and renders 
them mutually interesting and necessary for the in- 
vestigation of truth. 



INTRODUCTION. \X 

The author of the original work; a translation of 
which is herewith presented to the medical public, 
was for more than twenty years principal physician 
of one of the most popular hospitals of Paris, during 
which period he was more or less engaged in collect- 
ing the materials of the present work, in which he 
was assisted in his medico-pathological researches by 
M. Dejaer, chief physician of the Hospital of Liege, 
and M. Bouillaud, author of an accurate and beauti- 
ful work on encephalitis, and Editor of the present 
work, to whom the author was indebted for a consi- 
derable number of cases, and a great many valuable 
remarks and observations added to the manuscript 
confided to his special care and direction. 

M. Bouillaud, while house physician to the Hospi- 
tal Cochin, conceived a peculiar taste for the study 
of the diseases of the heart, and has analyzed, with 
greater precision than has hitherto been done, the 
phenomena peculiar to each disease, and thus placed 
the theoretical and physiological part of the work on 
a level with the anatomical. 

In order that we may have a more definite view of 
the improvements and discoveries made by M. Ber- 
tin in this branch of knowledge, we shall insert the 
principal part of the report of Dumeril and Pelletan, 
to the Royal Academy of France. 

In regard to the translation of the work, I have en- 
deavoured to give a literal and exact interpretation 

B 



x INTRODUCTION. 

of the facts described by the author, without having 
sought to attain that smoothness and polish of style 
more commonly found in works of imagination. The 
principal merit of the original work depends upon 
the great number of cases described, and the anato- 
mical classification of their arrangement. 

Charles W. Chauncy. 

New York, 
May 21st, 1833. 



INSTITUTE OF FRANCE, 



ROYAL ACADEMY OF SCIENCES. 



Paris, January 15th, 182L 

The Perpetual Secretary of the Academy of Na- 
tural Sciences, certifies that the following is extract- 
ed from the proceedings of the sitting on Monday, 
January 15th, 1821. — 

" From the time of Morgagni to the present day, 
the best medical writers, and all those who have con- 
tributed to the progress of science, have taken pa- 
thological anatomy for the basis of their researches. 
To speak only of the diseases of the heart, we might 
mention the labours of Lancisi, Senac, MM. Portal, 
Corvisart, Kreysig, Burns, Testa, Meckel, Hodgson 
and Laennec. 

The memoirs of M. Bertin, committed, by the 
Academy to MM. Pelletan, Dumeril and myself, is 
not inferior, in any respect, to the writings of any of 
the authors spoken of, and we might claim for M. 
Bertin, in many particulars, a priority of observa- 
tion and inquiry respecting many of the organic le- 
sions of the heart, which he communicated to the 



Xii INTRODUCTION. 

Academy at a period when some of the most esteemed 
works on the subject had not been published. 

In fact, when the author presented his first memoir, 
on the organic diseases of the heart, on the 10th of 
August, 1811, thickening of that organ had only been 
partially distinguished from the dilatation of the pa- 
rietes, and from enlargement of the cavities denoted 
by the term aneurism; it appears that the reverse, 
and entirely opposite state, as regards anatomy and 
physiology, had been confounded with the term thick- 
ening. Simply augmented nutrition of the muscular 
parietes of the heart does not appear to have been 
distinguished from those defections, or more profound 
alterations, induced by the nutrition of that organ. 
About this time M. Corvisart described these seve- 
ral alterations by the term active aneurism, without 
determining the circumstances, or the anatomical 
characters, which have a tendency to diminish and 
even destroy that active state, whether by the soft- 
ening or hardening of the parietes, or of the muscu- 
lar columnar of the heart, and of a multitude of other 
alterations resulting from an augmented nutrition, 
which frequently also thickens the parietes without 
rendering them hypertrophous. It was also at the 
same period that M. Portal considered this thicken- 
ing of the heart only as a transformation into a sub- 
stance unnatural to the muscular texture of that or- 
gan; and had thus been led to regard that anatomical 
condition as invariably of a passive nature. 

It was at this period that M. Bertin, after having 
been ten years employed in the hospital confided to 
his care, in collecting, comparing, and collating nu- 
merous cases, confirmed by inspections of the body, 



INTRODUCTION. Xlll 

attempted to demonstrate, in his first memoir, that 
the aneurism did not give an exact idea of the dilata- 
tion of the heart; that the activity too generally at- 
tributed to a species of dilatation of the parietes, ac- 
companied with thickening, should not be admitted, 
excepting in cases of increased nutrition of the mus- 
cular tissue; that this increased nutrition does not al- 
ways coexist with dilatation; that simultaneous dilata- 
tion and thickening do not constitute augmented ac- 
tivity of the muscular parietes, since the author had 
in vain sought to find these anatomical dispositions 
in a great number of observations; that frequently, on 
the contrary, the cavities of the heart were very 
much diminished (a disposition the first discovery of 
which appears to have appertained to M. Bertin;) 
and that at last the morbid activity of the heart be- 
came weakened in consequence of its complication^ 
especially when the thickening, at first partaking of 
the characters of the muscular texture, but losing af- 
terwards its density, consistence and colour, becomes 
hard, of a deep brown colour, softened and relaxed; 
or when it presents an inverse disposition, that is to 
say, hardening of its texture, met with most frequent- 
ly in the pillars and columns of the cavity of the ven- 
tricles. 

Such are the most remarkable results of the first 
memoir, confided to M. Corvisart by the Academy, 
in 1811, to make a report, but which his numerous 
occupations did not allow him time to present to you. 
We shall go on with the analysis of the other me- 
moirs of M. Bertin, which should only be considered 
as the development of the ideas and observations con- 
tained in the first part of his work. 



Xiv INTRODUCTION. 

Each of the forms of hypertrophy, considered more 
particularly in reference to -the left ventricle, ap- 
pears especially to have been thoroughly investigated 
in the three memoirs successively presented, about a 
year since, to the Academy. Thus M. Bertin, fol- 
lowing in his second memoir the same analytical me- 
thods, begins with an exposition of the facts and ob- 
servations proper to establish the first kind of hy- 
pertrophy, as follows: thickening, without dilata- 
tion of the left ventricle. This alteration is first con- 
sidered in its primitive state, then with the different 
complications which frequently accompany it. Each 
of these observations, presented with the prepara- 
tions, to several societies of medicine, is followed 
by reflections from which we may expect new and 
important discoveries. 

The object of the third memoir is to discover and 
establish the symptoms and organic alterations which 
characterize hypertrophy of the left and right ven- 
tricles, with diminution of their cavities. 

Senac has already consecrated one of the articles 
of his beautiful work to the diminished volume, nar- 
rowness of the cavities, or shrinking of the heart. 

Malpighi and Fabricius Hildanus speak of small, 
wrinkled and shrunken hearts; Corvisart notices the 
constriction of the left or right ventricle, with dimi- 
nution of the cavities, produced by a shortening of 
the parietes; occurring in consequence of indura- 
tions or cartilaginous and osseous alterations of the 
tricuspid or mitral valves. 

In the observations which M. Bertin has collected, 
he has observed that the volume of the heart was not 
sensibly altered; that the ventricles were, however, 



INTRODUCTION. XV 

more fleshy than in the natural state, and that the 
muscular thickening was evidently formed at the ex- 
pense of the cavity, without, however, appearing to 
present a trace of any alteration whatever. 

His third memoir contains six cases, remarkable as 
well in relation to the description of the symptoms as 
to the details of pathological anatomy. 

The fourth is consecrated to the investigation of 
hypertrophy of the parietes of the heart, accompanied 
by dilatation. The author has recognised this mor- 
bid disposition in ten of the c^ses detailed. He there 
explains the different degrees of hypertrophy of the 
left ventricle, the right ventricle and the auricles; he 
remarks that it is far from being uniform in the pari- 
etes of the heart, in the septum of the ventricles 
and auricles; that it varies in the columns carneae, 
and at different points of the parietes of the cavities; 
and that it offers different degrees, accordingly as the 
dilatation is greater or less than the proportional di- 
mensions of the corresponding cavities. 

The various degrees of alteration are described 
with much care by M. Bertin. 

From the labours and researches which this author 
has presented to the Academy, he has been enabled 
to ascertain, 1st. That in the different species of or- 
ganic lesions, the muscular texture may be more or 
less altered. 2nd. That the heart becomes thicker 
by dilatation, or without dilatation. 3rd. That thick- 
ening of the parietes offers two different anatomical 
characters, increase or alteration of nutrition, some- 
times existing simultaneously, at other times indivi- 
dually. M. Bertin proves that this thickening by hy- 
pertrophy, the principal object of the memoirs which 



XVI INTRODUCTION. 

we have been analyzing, offers three different forms, 
two of which had not been, before the year 1811, at- 
tached to the doctrine of the diseases of the heart, 
and which we have already noticed; that is to say, in- 
creased volume of the cavities of the heart, and dimi- 
nution of the cavities caused by hypertrophy. 5th. 
He thinks that the denomination aneurism is not ap- 
plicable in any respect to these two kinds of altera- 
tions. 6th. He affirms that it is necessary to be very 
careful not to call hypertrophies active dilatations, 
because the energy of the parietes is singularly modi- 
fied, sometimes even much weakened, either by the 
hardening or softening of the thickened parietes, and 
by all the other complications. 7th. He thinks, final- 
ly, that thickening, with or without dilatation of the 
parietes, should be distinguished according to its ana- 
tomical characters, and not according to the physio- 
logical phenomena which are so numerous and varia- 
ble. 

These various pathological views, since confirmed 
by recent and commendable labours, but which we 
must pass over, are especially adapted to impart a 
knowledge of the organic diseases of the heart, re- 
specting which M. Bertin has been one of the first to 
fix the attention of observers. They are not, undoubt- 
edly, new in the present day; but if we refer to the 
period when the author presented his first memoir, of 
which the others are only a development, we shall see 
that his labours are far from having been without 
their utility for science. 

The distinctions admitted by the author have been 
deduced from a great number of well-observed facts, 
and which have required a great deal of sagacity and 



INTRODUCTION. XV11 

patience of anatomical research. The author has al- 
ways been careful to confine himself to an exact de- 
scription of facts, and to compare the symptoms with 
the various results furnished by pathological anatomy. 

We think, also, that the labours of M. Bertin will 
powerfully concur to promote the knowledge of these 
diseases; we think, indeed, they have already served 
that purpose, and that his co-labourers will do no 
more than justice towards M. Bertin, by receiving 
his contributions favourably, and recognising the an- 
teriority of his researches in numerous organic alte- 
rations of the heart. 

It will, at all times, give us the greatest pleasure to 
be permitted to communicate the results of the la- 
bours of a man whose father was counted among the 
most distinguished members of the Academy, and 
who has left so many tokens of remembrance of anato- 
mical science. 

(Signed) Dumeril, Pelletan, Pinel, 

Reporters.- 

The Academy approves of the report and adopts 

its conclusions. 

Certified in conformity to the original. 

Perpetual Secretary, Counsellor of State, Of* 

ficer of the Royal Order of the Legion of 

Honour. 

B. Cuvier. 



TABLE OF CONTENTS. 



Page. 

Introduction by the Translator v 

Report of the Royal Institute of France xi 

Introduction - -- - - - - - xxv 

First Part. — Anatomical and Physiological Considera- 
tions respecting the Heart - xxv 
Second Part. — Historical View respecting the Diseases 

of the Heart and Aorta - xlix 

BOOK I. 

DISEASES OF THE AORTA. 

General Observations -------25 

CHAPTER I. 

Inflammation of the Aorta; Internal Membrane of the 
Heart and Pulmonary Artery, and its Consequences, 
such as Ulcers, Perforations, Cartilaginous and Calcari- 

ous Degenerations, &c. 27 

Art. I. — Observations on Inflammation of the Aorta, In- 
ternal Membrane of the Heart, and Pulmo- 
nary Artery -27 

Art, II. General History of Inflammation of the Aorta 

and Internal Membrane of the Heart - §5 

§ 1st. Anatomical Signs 66 

§ 2nd. Physiological Signs 76 



XX CONTENTS. 

CHAPTER II. 

Dilatation and Aneurism of the Aorta. 

Preliminary Considerations 88 

Art. I. — Observations relative to Dilatation and Aneu- 
rism of the Aorta, whether true or false 89 
Art. II. — General History of Dilatation and Aneurism 

of the Aorta 127 

§ 1st. Formation and Anatomy of the various kinds of 

Aneurism 127 

§ 2nd. Influence of the Aneurisms of the Aorta on the 

Parts with which they are found in Contact - 138 
§ 3rd. Signs and Diagnosis of Aneurism of the Aorta - 143 
§ 4th. Treatment of Aneurism of the Aorta, and the Mode 

of Cure 154 

CHAPTER III. 

Contraction and Obliteration of the Aorta - - 162 

CHAPTER IV. 

Induration and Vegetations of the Valves of the Heart, 

and Constriction of its different Orifices - 170 

Preliminary Considerations -170 

Art. I. — Observations on Induration and Valvular Vege- 
tations - 172 

§ 1st. Indurations of the Valves 172 

Art. II.- — General History of Induration and Vegetations 
of the Valves of the Heart, and Constric- 
tion of their several Orifices - 212 
§ 1st. Anatomical Description of the Induration of the 

Valves of the Heart, in general - - - 212 
§ 2nd. Anatomical Description of the Vegetations of the 

Valves of the Heart, in general - 221 

§ 3rd. Of the Signs and Diagnosis of the Induration and 

Vegetations of the Valves of the Heart - - 221 
§ 4th. Of the Causes of the Vegetations and Indurations 

of the Valves of the Heart - - - - 231 
§ 5th. Of the Treatment of the Vegetations and Indura- 
tions of the Valves ----- 032 



CONTENTS. XXI 

BOOK II. 

OF THE DISEASES OF THE HEART. 

Preliminary Considerations ------ 235 

§ 1st. Diseases of the Pericardium - 237 

CHAPTER I. 

Of Pericarditis and its Consequences; such as Albuminous 
Effusions, False Membranes, Cellular Adhesions, Fi- 
bro-cartilaginous or Cartilaginous Membranes, Ossifica- 
tions of the Pericardium, &c. ----- £38 
Art. I. — Particular Observations respecting Pericarditis, 

Acute or Chronic - 238 

Art. II. — General History of Pericarditis - 263 

§ 1st Signs of Acute Pericarditis - - . 266 

§ 2nd. Signs and Diagnosis of Chronic Pericarditis - 268 

CHAPTER II. 

Of Hydro and Pneumo-pericarditis - - - - 273 
7. Particular Observations - 273 
II. General History of Hydro-pericarditis and Pneu mo- 
Pericarditis ------- org 

SECTION II. 

Diseases of the Muscular Substance of the Heart - - 281 

CHAPTER I. 

Hypertrophy or Nutritive Irritation of the Heart. 

Preliminary Considerations 287 

Art. I. — Cases of Hypertrophy of the Heart - - 287 

§ 1st. Cases of Hypertrophy of the Left Ventricle - 287 

§ 2nd. Cases of Hypertrophy of the Right Ventricle - 314 

§ 3rd. Hypertrophy of the Auricles - - - - 331 
§ 4th. Simultaneous Hypertrophy of several or of all the 

Cavities of the Heart 332 



XXli CONTENTS. 

Art. II. — General History of Hypertrophy or Nutritive 

Irritation of the Heart 337 

§ 1st. Anatomy of the Hypertrophy of the Heart - - 337 
§ 2nd. Formation of Hypertrophy of the Heart - - 341 
§ 3rd. Of the Causes of Hypertrophy of the Heart - 344 

§ 4th. Of the Influence of Hypertrophy of the Ventricles 

on the other Organs, and especially on the Brain 

and Lungs - 346 

§ 5th. Of the Symptoms and Diagnosis of Hypertrophy 

of the Heart 349 

§ 6th. Progress and Termination of Hypertrophy of the 

Heart 361 

§ 7th. Treatment of Hypertrophy of the Heart - - 362 

CHAPTER II. 

Of Dilatation or Aneurism of the Heart 

Preliminary Considerations 565 

Art. I. — Cases of Dilatation or Aneurism of the Heart - 367 
Art. II. — General History of Dilatation or Aneurism of 

the Heart 371 

§ 1st. Anatomical Characters and various Forms of Dila- 
tation of the Heart 371 

§ 2nd. Formation and Causes of the Dilatation of the 

Heart 373 

§ 3rd. Of the Symptoms and Diagnostics of the Dilatation 

or Aneurism of the Heart - 377 

§ 4th. Of the Effects of Dilatation or Aneurism of the 

Heart 379 

§ 5th. Treatment of the Dilatation or Aneurism of the 

Heart 381 

i CHAPTER III. 
Of Atrophy of the Heart 383 

CHAPTER IV. 

Of the Inflammatory Irritation of the Muscular Substance 
of the Heart, or of Carditis and its Consequences; such 
as Abscesses, Ulcers, Perforations, Gangrene, &c. 

Preliminary Considerations - 387 



CONTENTS. XX111 

Art. I.— Of Softening of the Heart, (Carditis) - - 391 
Art. II. — Of Induration of the Muscular Substance of the 

Heart 396 

Art. III. — Of Gangrene or Sphacelus of the Heart - 402 

CHAPTER V. 

Of Cancer and the other Accidental Productions of the 
Heart, which have nothing Analogous in other Parts of 

the Animal Economy 405 

§ 3rd. Of the Diseases of the Vessels of the Heart - 409 

§ 4th. Of the Diseases of the Cellular Texture of the 

Heart 422 

§ 5th. Of the Defective Conformations and Positions of 

the Heart 426 

Art. I. — Of the Defective Conformation of the Heart, in 

general, and of the Communication of the 

Right and Left Cavities, in particular - - 426 

Art. II. — Of the Displacements of the Heart - - 435 

§ 6th. Of the Concretions of the Blood, most commonly 

distinguished by the term Polypi, of the Heart 

and Large Vessels 439 

/. Anatomical Characters of Polypous Concretions - 441 
II. Formation of Polypous Concretions ... 443 
III Of the Effects and Symptoms of Polypous Concre- 
tions, in general -^ 444 

§ 7th. Of the Reciprocal Complication of the Various 

Diseases of the Heart 448 



INTRODUCTION. 



Anatomy, physiology, and pathology, have each 
of them such intimate relations and close connexions 
with each other, and mutually derive from each other 
such useful light, that they constitute, perhaps, less 
three absolutely distinct sciences, than three branches 
of one and the same science. Reasons, the truth of 
which no one can for a moment doubt, have induced 
us to prefix to the history of the diseases of the 
heart an abridged description of the structure and 
functions of that organ. We shall devote the first 
part of our introduction to this description, and in 
the second, present some historical researches on the 
diseases which form the subject of the work. 



PART I. 

ANATOMICAL AND PHYSIOLOGICAL CONSIDERATIONS 
RESPECTING THE HEART. 



§ I. ANATOMICAL CONSIDERATIONS. 

The heart is a hollow organ, principally of a mus- 
cular nature, having the form of a cone reversed: it 

D 



XXVlii INTRODUCTION . 

ing is known by the name of foramen Botalli.* The 
cavity of the ventricles, separated from each other 
by a common division, presents the orifices of the 
pulmonary arteries and aorta. These orifices, as well 
as those by means of which the auricles and ventricles 
communicate with each other, are furnished with 
membranous folds, which have been distinguished by 
the name of valves. The valves adapted to the auri- 
culo- ventricular orifices have their free edges cut into 
a great number of dentations, and, farthermore, deep- 
ly divided into three principal lingual flaps in the 
right ventricle, and into two only in the left ventri- 
cle. It is in consequence of this arrangement that 
the name of tricuspid or triglochyne valve has been 
given to that valve which occupies the edge of the 
right auric ulo- ventricular orifice, and the name of 
bicuspid or mitral to the left auriculo-ventricular 
valve. When these valves are raised, they close the 
auriculo-ventricular orifices almost hermetically, like 
valves. These orifices, the circumference of which 
is elliptical, are bordered by a line or whitish zone, 
more apparent on the side of the auricles; and which 
appears owing, in part, to the presence of a small quan- 
tity of fat situated under the internal membrane, and 
in part to that of a tendinous ring, imbedded in the 
substance of the heart. The valves annexed to the 
arterial orifices of the heart, are known by the name 
of semilunar or sigmoid valves: the aortic valves, to 
the number of three, like the pulmonary valves, are 
larger and thicker than the latter. They are all ar- 
ranged in such a manner as to oppose a sufficient ob- 

f Hole of Botallus, or foramen ovale, 



INTRODUCTION. XXIX 

stacle to the retrograde course of the blood in the 
ventricles. Their free edge presents at the middle 
part a small tubercle which is called the tubercle of 
Arantius. 

The muscular substance of which the heart is es- 
sentially composed, is denser, firmer, and of a deep- 
er red than that of the voluntary muscles, and is com- 
posed of numerous fibres, the arrangement of which 
has been for a long time an impenetrable enigma for 
the anatomists. Steno was the first who exerted 
himself to unravel that inexplicable muscular net- 
work; his efforts were unsuccessful. The attempt of 
many anatomists succeeding Steno, were scarcely 
more fortunate. Finally, in these latter times the in- 
genious researches of MM. Wolff, Duncan and Gerdy, 
have succeeded in unravelling the tortuous and cir- 
cumvolute fibres of the heart. It results from the re- 
searches of these anatomists, that the ventricles are 
formed of many muscular layers placed one over the 
other, the number of which differs in each of them :* 
besides, the direction and extent of the fibres which 
constitute these muscular planes, are not the same. 
The fibres of the external layers are, in general, ob- 
lique, from above downward, from before backward, 
and from right to left: the middle are arranged in the 
contrary direction, and the more profound, which 
are united together to form species of projecting co- 
lumns on the interior of the ventricles, are, for the 
most part, longitudinal.! According to a law disco- 

* These muscular layers are six in number for the left ventricle, and three 
only for the right ventricle, which explains why the first is much thicker 
than the second. 

f The superficial layers occupy the whole circumference of the ventricles 
in passing round the apex of the heart, whilst the others diminish in length 



XXX INTRODUCTION. 

vered by M. Gerdy, all the fibres, whatever may be 
their length, situation, or direction, are disposed in 
the forms of loups, the convexity of which looks to- 
wards the apex of the heart, and which are more or 
less superficial at one extremity, and deep-seated at 
the other; so that the external and internal fibres are, 
in fact, the same, being reversed after having passed 
through the substance of the ventricle. The extre- 
mities of these muscular loops are uniformly inserted 
into the base of the heart, in the circumference 
of the various auricular and arterial orifices of the 
ventricles, either immediately or by the tendons at- 
tached to the auriculo- ventricular valves. 

The auricles have a structure equally complicated : 
they are composed of two fleshy layers, the one ex- 
ternal and the other internal. In the right auricle 
the muscular tissue is less abundant than in the left, 
and leaves intervals between the fibres, where the in- 
ternal and external membrane of the heart are in im- 
mediate contact. This disposition is very remarka- 
ble in certain individuals affected with a considera- 
ble dilatation of the right auricle, with thickening of 
its fleshy fibres. 

The muscular fibres of the heart, uniting in fasci- 
culi, form on the interior of that organ what the ana- 
tomists call the fleshy columns of the heart. These 
columns differ in the ventricles and in the auricles, 
and even in each of its several cavities. They are 
much more developed in the ventricles than in the 
auricles; those of the right ventricle are more nume- 
rous and stronger than those of the left; the left au- 

and breadth in proportion as they become deeper; hence the reason why the 
ventricles are thicker at the base than the apex. 



INTRODUCTION. XXXI 

ricle offers them only on its appendix, whilst the right 
is provided with them also on the right and anterior 
side. The fleshy columnar are interwoven with each 
other in a variety of ways, and give to the internal sur- 
face of the ventricles an appearance similar to a sort of 
network the meshes of which are of unequal size, and 
the filaments of various lengths. Some of these mus- 
cular pillars, detached from the heart in the whole 
of their middle part, are only held by their extremi- 
ties. Many of the fleshy columnse give origin to a 
multitude of small tendons, which are fixed on the 
free edge of the auricular valves : this arrangement 
permits us to regard these fleshy fasciculi as the ten- 
sor muscles of the several valves to which they are 
attached. 

The tendons of which we have spoken, are not the 
only part of an albugineous nature which the heart 
possesses. In fact, we find the tendinous, ligamentous, 
or fibrous tissue, at the point of union of the ventri- 
cles with the auricles, and with the aorta, and pul- 
monary arteries, and in the duplicature of the valves 
themselves. This tissue forms, at least in great part, 
the valvular circles which we observe round the au- 
ricular orifices, in the form of whitish zones. It is 
this tissue, which, by becoming converted into a car- 
tilaginous or osseous texture, determines the diseases 
which we shall hereafter describe.* The natural con- 
sistence of the tendinous circles, situated at the ori- 
fices of the heart, very much resembles that of the car- 
tilages or fibro-cartilages. 



* See the chapter which treats of the indurations of the valves and the 
contraction of the orifices. 



XX xii INTRODUCTION, 

The external membrane of the heart is a depen- 
dence of the serous fold, which enters into the com- 
position of the pericardium, of which it covers the 
external or fibrous lamina. 

The internal membrane of the heart, continuous 
with that which covers the interior of the vessels, 
participates in the right cavities with the characters 
of the internal membrane of the veins, and in the left, 
with the properties of the internal membrane of the 
arteries. It is this which forms, by folding on itself, 
and around the fibrous texture indicated above, the 
valves of the heart. 

We find very little cellular tissue in the composi- 
tion of the heart, most of the muscular fibres of which 
are united by prolongations of the same nature with 
them. There is no cellular membrane, excepting on 
the surface of the organ, where it may be found un- 
derneath the serous membrane, in the clefts which 
separate the ventricles; and those which are found at 
the junction of the ventricles, unite with the au- 
ricles. 

The arteries of the heart arise from the aorta imme- 
diately after its origin; they take the name of coronary, 
and are two in number, one going to the right and the 
other to the left. The larger branches divaricate, and 
spread over the whole surface of the organ, from the 
base to the apex, while the smaller branches merely 
ascend toward the auricles. The veins of the heart 
have almost as many branches as the arteries, but af- 
terwards unite to form a common trunk, generally de- 
nominated the great coronary vein. Numerous small 
branches communicate individually with the right 
auricle, and constitute so many small coronary or car- 



INTRODUCTION. XXxiii 

diac veins. The lymphatic vessels of the heart are 
very numerous; they follow the course of the blood- 
vessels, and are afterwards collected in two principal 
branches, one of which passes before, and the other 
behind the aorta. The nerves of the heart come from 
the plexus formed by the branches of the trisplanch- 
nic or great sympathetic, and the pneumo-gastric 
nerve. They have been accurately described by Scar- 
pa, who has demonstrated, contrary to the opinion of 
Behrends and other anatomists, that these nerves send 
out numerous branches into the proper texture of the 
heart. 

The heart presents numerous varieties of volume, 
according to age, sex, and other circumstances. It 
would be very important, if we could determine, pre- 
cisely and geometrically, the normal size of the heart, 
the absolute or relative thickness of the parietes of 
the various cavities and their natural capacity; but 
this is almost impossible. It is the experienced eye 
only that can distinguish whether or not a heart pos- 
sess the proportions conformable to those of health. 
The comparative dimensions laid down by M. Laen- 
nec appear to be sufficiently accurate; we shall, there- 
fore, give them in this place: u The heart, including 
the auricles, ought to have a volume a little inferior, 
equal, or very little superior in size to the fist of the 
subject. The parietes of the left ventricle ought to 
be a little more than double the thickness of that of 
the parietes of the right ventricle :* they ought not to 
yield when cut upon with the scalpel. The right ven- 

* This should be understood only in reference to the adult heart, for 
in the foetus and the very young" child, the thickness of the left ventricle 
does not much exceed that of the right 

E 



XXxiv INTRODUCTION. 

tricle, a little larger than the left, presents more vo- 
luminous fleshy columnar and, notwithstanding the 
lesser thickness of its walls, should flatten inward 
after the incision. Reason indicates, and observation 
proves, that, in a healthy subject of a good constitu- 
tion, the four cavities of the heart are very nearly 
equal to each other. But as the parietes of the auri- 
cles are very thin, and those of the ventricles are 
much thicker, the result is, that the auricles form 
hardly one-third the whole volume of the organ, or 
about half that of the ventricles. *** These asser- 
tions, it is true, seem contradictory to observations 
made on the dead body; where we almost constantly 
find the right cavities larger than the left. But 
it is to be observed that this increased thickness 
of the right cavities, is not so much a normal condi- 
tion as the result of some disease, or, at least, of the 
distention which these cavities have undergone, 
when, during the anguish of the agony, the blood, in- 
capable of permeating the lungs, accumulates in the 
cavities, and distends them. We should add, that the 
difference in capacity, which we so frequently find 
.after death in the two hearts, is invariably observed, 
according to the experiments of Legallois, in animals 
which have died of asphyxia: in the latter case, how- 
ever, the disproportion is considerably greater. How- 
ever it may be, these experiments will serve to prove 
that we ought not to consider the equal capacity of 
the right and left cavities as a truth perfectly demon- 
strated; and will not permit us to consider a moderate 
inequality of capacity as the result of a pathological 
condition. 

* De PAuscultat. Mediate, torn. ii. p. 270 et 279. 



INTRODUCTION. XXXV 



§ II. PHYSIOLOGICAL CONSIDERATIONS. 

And, now that we are acquainted with the anato- 
mical structure of the heart, let us pass on to the study 
of the functions of that important organ, and let us 
inquire into the function which it performs in the 
mechanism of the circulation. The following is 
what we have gathered from experience and observa- 
tion on this subject. The auricles and ventricles 
perform, successively, alternate contractions and di- 
latations. The two ventricles contract and dilate at 
the same time: so it is with the auricles. The first 
of these movements is essentially of an active nature, 
and is similar to the contraction of the external mus- 
cles, and is generally called the systole; the second 
is, most probably, of a passive nature, like the relax- 
ation of the external muscles, after contraction, and 
is called the diastole. The effect produced by the 
diastole is evidently to suck up or respire the blood; 
w T hilst that of the contraction is to throw this fluid 
out of the cavities in which it is introduced during 
the diastole. The auricles, by their contraction, cause 
the blood to pass into the ventricles; these, by con- 
tracting in their turn, project the blood from the 
right ventricle into the pulmonary artery, and from 
the left into the aorta. If we ask the reason why, 
during the contraction of the ventricles, the blood 
does not pass into the auricles, as it does into the ar- 
teries above-named, we should reply that the reflux 
of the blood into the auricles would, in fact, take 
place if the mitral and tricuspid valves, the true or- 
ganized valves, did not perfectly close the aurieulo- 



XXXVI INTRODUCTION. 

ventricular orifices, at the time the ventricles are 
about contracting. In like manner, the blood does not 
fail to retrograde, as it were, into the ventricles 
during the contraction of the aorta and pulmonary- 
artery, if the sigmoid valves are not opposed to it in 
closing the arterial orifices of the heart. The reflux 
of which we have been speaking here, wilt be so 
much the more inevitable without the presence of the 
valve, that, during the contraction of the ventricles, 
these auricles dilate, as, during that of the arteries, 
the ventricles, of themselves, dilate. We shall find, 
in the progress of this work, that pathology furnishes 
us with numerous facts to prove the great importance 
of the valves in the mechanism of the circulation. 
We shall see that the lesion of them produces very 
great disturbance of the circulation; and, consequent- 
ly, sudden death, if the medical art do not furnish 
means to remove it. The anatomical disposition of 
the valves is sufficient, of itself, to demonstrate in what 
manner the column of blood passes from one heart to 
the other. It is indubitable, in fact, that, after this 
arrangement, the blood must circulate from the au- 
ricles into the ventricles, and from these into the ar- 
teries; afterwards to return, by means of the veins, 
into the auricles, and so on. It is farther evident 
that the same phenomena absolutely occur in both 
hearts, in the right and in the left heart.* 

But the blood which circulates from one of these 
hearts to the other, is very far from being the same 

* The contractions of the left ventricle are stronger than those of the 
right, only in consequence of a greater thickness of its parietes; increased 
thickness and force are quite necessary, since the distance to which this ven- 
tricle must propel the blood is much greater than that of the right. 



INTRODUCTION. XXXVli 

in each of them. This fluid, in fact, undergoes great 
changes by traversing, on the one side, the capillary sys- 
tem of the lungs to pass into the left heart; and, on the 
other side, the capillary system of all the organs, to 
return to the right side of the heart. In the first of 
these passages, the blood is found in contact with the 
air, acquires new properties, becomes, as it were, 
vivified, and fitted to excite, and nourish all the or- 
gans; in the second passage, on the contrary, the blood 
becomes disarterialized, if we may be allowed to use 
such an expression, loses the stimulating, nutrient, and 
vivifying power with which it had been animated, 
and does not resume it, excepting when it returns to 
imbue the lungs. The two kinds of blood flowing 
through the cavities of the heart, are distinguished 
by giving the term arterial to that which passes 
through the left cavities; and venous, to the blood 
flowing into the right cavities. We did not wish to 
pass over in silence the modifications presented by 
the blood in the two hearts, because, perhaps, they 
may serve to explain some of the pathological pheno- 
mena which we shall have occasion to speak of here- 
after. 

At the moment of the contraction of the ventricles, 
the apex of the heart strikes the left lateral parietes 
of the chest, between the cartilages of the fifth and 
sixth ribs. This phenomenon appears singular at 
first sight, since it seems to indicate a kind of elonga- 
tion of the heart; while the systole, which accompa- 
nies it, consists of a contraction, by means of which 
this hollow muscle becomes shortened in every direc- 
tion. We can, nevertheless, account for the pheno- 
menon when we reflect, that, during the contraction 



XXXvill INTRODUCTION. 

of the ventricles, the apex, which is moveable, be- 
comes extended and bent, as it were, on their base, 
which is more fixed, and represents a sort of point of 
support. Farthermore, as the auricles dilate, during 
the contraction of the ventricles, we may conceive 
how this dilatation may carry the heart forward, and 
concur in the production of the phenomenon in ques- 
tion. 

It is not only by sight that we are able to ascertain 
the movements of the ventricles and auricles; we can, 
also, study them, by means of touch, and especially 
through the medium of hearing. M. Laennec, to 
whom science is indebted for this new mode of ex- 
ploration of the pulsations, insists, with reason, on the 
superiority which it possesses over all the others; 
and the only one, in fact, in connexion with that of 
touch, which can be practised on man. 

We shall now proceed to an analysis of the pheno- 
mena observed in auscultating the pulsations of the 
heart, either with the ear alone, or the ear assisted 
by the instrument invented by M. Laennec. We 
ought to say, in advance, that these pulsations have 
been analyzed with so much skill by that celebrated 
observer who first studied them in this connexion, 
that we have scarcely any thing to add to what has 
been already published on the subject. We shall ex- 
amine them, as he has done, in relation to their 
rhythm, sound, shock, and extent, 

1. Rhythm of the Pulsations of the Heart. 

Hearing, as well as sight and touch, prove that the 
auricles contract simultaneously, as well as the ven- 
tricles; and that the contractions of the latter alter- 



INTRODUCTION. XXXIX 

nate with those of the former. In fact, if we apply 
the ear attentively, we shall presently distinguish, 
during the pulsations of the heart, a double sound; 
one of which, duller and isochronous with the pul- 
sations of the arteries, announces the contraction of 
the ventricle; while the other, louder and clearer, 
results from the auricular contractions. There does 
not exist any appreciable interval between the con- 
tractions of the ventricles and the auricles; so that 
the observer of little experience frequently cannot 
distinguish more than one sound, and takes the one 
which accompanies the auricular contractions for a 
kind of reverberation of that which is produced by 
the ventricles : but, with a little practice, nothing is 
more easy than to discriminate the double sound, or 
the tic-tac to w r hich we refer. 

The duration of the sound, the kind of clicking 
which accompanies the contraction of the auricles, is 
evidently shorter than that of the ventricular sound; 
consequently, the duration of the auricular contrac- 
tions themselves is less than that of the ventricular 
contractions; a fact which had been merely suspect- 
ed by Haller. Between the sound of the auricle and 
ventricle, we observe a very distinct interval of re- 
pose, although its duration is very short. This is 
followed by a sound which indicates the contractions 
of the ventricle, to which succeeds the auricular 
click, and so in succession. 

The respective duration of the contractions of the 
heart has been determined by M. Laennec in the 
following manner : of the total duration of time ne- 
cessary for the successive contractions of the various 
parts of the heart, one-third, at most, or one quarter 



Xl INTRODUCTION. 

is taken up for the systole of the auricles; a quarter, 
or a little less, by an absolute repose, and half, or 
nearly so, by the contraction of the ventricles. 

This auscultation, it is manifest, can only apply to 
the most common state; for there are cases to which 
it is not applicable. It is in this way, for example, 
that the interval of repose which the heart enjoys 
will be more or less prolonged, accordingly as the 
contractions are either slower or quicker, more ap- 
proximated or more remote. 

However this may be, the preceding remarks de- 
monstrate that the heart, far from being in a state of 
continual movement, offers alternations of repose and 
action, like all the other muscles, in such a manner, 
that, according to the approximate calculations above 
established, out of the twenty-four hours, the ven- 
tricles have twelve hours' repose, and the auricles 
eighteen.* 

2. Of the Sound of the Pulsations of the Heart. 

We have already noticed this sound in the pre- 
ceding article; we have seen that it is double, and 
that that which accompanies the contractions of the 
ventricles is more prolonged, but duller than the 
one heard during the systole of the auricles. We 
shall add here, that the sound heard in the infe- 
rior part of the sternum appertains particularly to 
the right cavities, whilst that of the left cavities is 
more especially heard between the cartilages of the 
fifth and sixth ribs; that, farthermore, the sound of 
the right cavities is to be heard more particularly in 

* This calculation supposes that the cavities of the heart arc entirely pas- 
sive during their dilatations. 



INTRODUCTION. xli 

the whole right side of the chest, and that of the left 
cavities in the corresponding side of the thorax. 

3. Of the Shock or Impulse of the Pulsations of the 

Heart. 

It is evident that it is not only by means of hear- 
ing, but also through the intervention of touch or 
sight, that we can obtain an idea of the impulse of 
the heart. If, then, we place this phenomenon among 
those which may be recognised by the practice of 
auscultation, it is that in this mode of exploration, 
the ear in immediate or mediate contact with the 
thoracic parietes becomes a species of sense of touchy 
or, at any rate, performs the same functions. Final- 
ly, the hand, alone, or armed with an instrument 
adapted to transmit the movement, will be sufficient 
to study the characters of the shock determined by 
the contractions of the heart. 

We appreciate the intensity of this shock by the 
force with which the hand or any other part applied 
to the region of the heart is raised, struck or re- 
pelled. In some individuals, those of a nervous tem- 
perament, for example, this impulse is very well dis- 
tinguished at first sight, and sometimes produces an 
extensive movement, which raises the thoracic pa- 
rietes, the epigastric region, and even the clothes 
covering those parts. 

4. Of the Extent of the Pulsations of the Heart. 

The extent of the pulsations of the heart should be 
considered relatively both to the shock and to the 
sound. In relation to the first, this extent is very 
inconsiderable, and is found circumscribed in the 

F 



Xlii INTRODUCTION. 

precordial region itself, and in individuals somewhat 
corpulent, the impulse is scarcely sensible, even in 
this region, as if it had been deadened by the soft 
parts situated in front of the heart: in relation to the 
second, that is to say, in relation to the sound, the 
extent of the pulsations of the heart is not limited to 
a space so narrow. Full flesh is a circumstance 
which absorbs, in some measure, a part of the sound, 
whilst emaciation is favourable to its propagation: 
also, while, in the first case, the space in which the 
pulsations of the heart may be heard is sometimes re- 
stricted to the precordial region, in the second they 
are heard in the whole anterior part of the chest. 
There are, also, other circumstances which favour 
the transmission of the sound of the pulsations of the 
heart, and increase it in a very remarkable manner: 
this may be observed, for example, in the case of he- 
patization of the tubercles of the lungs, or effusion 
into the cavities of the pleura, &c. 

The knowledge of the phenomena which we shall 
presently point out is of the highest importance for 
the physician desirous of treating diseases only after 
having exactly determined the diagnosis. We do not 
hesitate to say, that the happy discovery of ausculta- 
tion has diffused, within a few years, more light on 
the diagnosis of the diseases of the heart than all the 
other modes of exploration had done for two centu- 
ries: this may easily be conceived. In fact, the sen- 
sible and local signs are the only ones which furnish 
positive data respecting the diagnosis of diseases; but, 
heretofore, these signs were reduced to those trans- 
mitted by sight and touch; and, as the heart, hidden 
in the depth of the chest, is almost completely with- 



INTRODUCTION. xliii 

drawn from these two senses, it is very clear why the 
diagnosis of these diseases has remained so long in 
profound obscurity. Auscultation, in creating for us, 
at it were, a new medical sense, has at last succeed- 
ed in dissipating this long-continued darkness. In 
the present day, instead of the eye, we employ the 
seeing ear, if we may be allowed such an expression; 
which, if attentively applied, collects all the symp- 
toms of the heart's motions, and renders the diagnosis 
of the diseases of that organ as easy and as sure as 
that of the chirurgical diseases the best known. Thus, 
augmentation, or impulse of the pulsations of the 
heart, denotes hypertrophy; the sounds of the same 
pulsations, clearer, stronger, and more extensive than 
in the natural state, announces, with certainty, a di- 
latation of the heart; thus, the sound of a bellows, or 
a file, heard during the contractions of that organ, is 
a symptom which does not permit us to mistake the 
existence of contraction of the orifices, &c. Univer- 
sal respect, therefore, is due to the ingenious obser- 
ver, who has enriched medicine by the discovery of 
a mode of exploration, the precious and fruitful re- 
sults of which we shall take pleasure to record ! 

After having studied the action of the heart, after 
having analyzed its most sensible phenomena, it is in- 
teresting to direct our regards more profoundly, and 
to determine what is the principle of the movements 
of the great spring of the circulating system. We 
shall not mention the numerous hypotheses which 
have been proposed on this subject; but we shall say 
something of the opinions which experience and ob- 
servation have led us to adopt. Now, this experience 
and observation would appear to have demonstrated 



xliv INTRODUCTION. 

that the principle of the contractions of the heart re- 
sides in the nervous system. But where is the ner- 
vous centre which presides over these contractions? 
Legallois, supported by beautiful experiments, has 
advanced that the heart derives its principle of mo- 
tion from the medulla spinalis; a conclusion which is 
defective only in this, that it exaggerates the influ- 
ence of the medulla spinalis, on the contractions of 
the heart. This influence is not indispensable for 
their production; it is not even the immediate prin- 
ciple, for the heart beats in the fcetus deprived of 
the medulla spinalis, as has been proved in the obser- 
vations related by M. Lallemand, in his thesis. Be- 
sides, Wilson, Philip and M. Clift have seen, in their 
experiments, the pulsations of the heart survive the 
destruction of the medulla, especially when the ani- 
mals were young, and the medulla was destroyed 
slowly. It is in the ganglionic system of the nerves, 
or the great sympathetic nerve, that we are to find 
the seat of that principle which governs the contrac- 
tions of the heart. If the motions of the heart cease 
soon after the medulla spinalis has been destroyed, it is 
owing to the intimate connexion existing between all 
parts of the nervous system, in general, and the reci- 
procal dependence which they have on each other, a 
dependence which is more fully disclosed, in propor- 
tion as the animal appertains to a class more elevated 
in proportion to its youth. We believe, then, that 
we shall be able to admit that the heart receives, 
through the intermedium of the plexuses furnished 
by the great sympathetic, the principle of its move- 
ments, and that, in the natural state, the presence of 
the blood in the cavities of the heart, is the agent 



INTRODUCTION. xlv 

destined to excite these plexuses, as the will stimu- 
lates the nerves which convey motion to the muscles 
submitted to its will. If it be true, that the action 
of the heart be thus under the immediate influence of 
the great sympathetic, we may easily conceive how 
it happens that the movements of that organ are not 
subjected to the influence of the will;* although the 
passions of the soul have such a powerful influence 
over them. Such is, indeed, the intimate relation of 
the affective faculties with the movements of the 
heart, that most philosophers regard that organ as 
the seat of the passions; and that, in all languages, the 
word heart is frequently employed as synonymous 
with sentiment, affection^ soul, passion. Whether 
this be true or not, it is incontestable that all the ac- 
tive passions powerfully modify the movements of the 
heart; some of them excite, others augment, and some 
convert them into violent palpitations; others distend, 
or momentarily release them, and sometimes perma- 
nently. In this respect, we might say, that of all our 
modes of expression the heart is the most faithful; and 
that it is the interpreter of all our most sincere emo- 
tions. But the moral affections are not the only ones 
which react, as it were, upon the heart. This organ, 
eminently sympathetic, perceives, and, as it were, par- 
ticipates in the purely physical affections of our or- 
gans; so, also, it is sufficient to interrogate these pul- 



* Stahl, it is true, cites, the example of Captain Townsend, who could 
govern, at will, the contractions of his heart. But suck a fact, in spite 
of the authority of Stahl, appears, at least, doubtful. It agrees, in other re- 
spects, very well with the system of this great physician, who, by placing 
under the influence of the soul, all the organic phenomena, thus assimi- 
lated the movements of the heart with those of the voluntary muscles. 



Xlvi INTRODUCTION. 

sations, in order to appreciate the state of calmness 
or agitation of the soul : it is, also, sufficient to ex- 
plore them, to ascertain in what state the body is 
found, as the physician practices every day in feeling 
the pulse. 

But if, on the one part, the heart feels with so much 
vivacity the affections and sufferings of all the other 
organs; on the other hand, it does not influence them, 
in its turn, in a less remarkable manner, either in the 
physiological or the pathological state. In fact, is it 
not the heart, which, like an inexhaustible fountain, 
distributes to all the organs the fluid necessary for 
their well-being and their functions; and which gives 
to them, as it were, life with the blood which it sends 
to them? Is it not the heart which impresses, by its 
impulses, the arterial systems of all parts of the body, 
excites their actions, and contributes, perhaps, to the 
production of animal heat? Do we not observe the 
most alarming symptoms to accompany the diseases of 
the heart of the most trivial character, as contraction 
of the orifices, for example? Lastly, is not sadden 
death the consequence of syncope or cessation of the 
action of the heart? and do not real and general 
death frequently commence with a lesion of that or- 
gan? 

These last remarks are well calculated to demon- 
strate the very great importance of the part per- 
formed by the heart in the human fabric; which Cor- 
visart calls, with reason, the great spring; and Bor- 
deu has not exaggerated this importance, when, in 
his metaphorical language, he has told us, that the 
heart is one of the beauties of the vital tripod. 

In the mean time, if we reflect that the heart is, at 



INTRODUCTION. xlvil 

once, the principal instrument of the circulating ap- 
paratus, and an organ of sympathy and expression; if 
we reflect, consequently, that all the causes which 
trouble, disturb, or disorder the circulation, propa- 
gate their influence to the heart itself; that the pas- 
sions of the soul react on it; that the most common 
diseases, such as fevers and inflammations, produce a 
more or less distinct shock; that numerous agents, in- 
troduced into the current of the circulation,* irritate 



* Among* the numerous causes calculated to produce diseases of the heart 
and large vessels, Lancisi, Morgagni, Corvisart, and others, have enume- 
rated the various kinds of virus, and particularly the venereal virus. They 
have considered the vegetations, which are sometimes developed on the 
valves of the heart, especially, to be of a syphilitic nature; this assertion, 
however, appears to us too general. We have opposed this opinion, in a 
memoir presented to the Society of the Faculty of Medicine, of Paris, in 1812. 
Long experience in a hospital especially appropriated to the treatment of ve- 
nereal diseases, and in another, where subjects affected with those diseases are 
not received, have apprized us that the vegetations spoken of, are very rarely 
met with in individuals who die of syphilitic disease; while it is not unfre- 
quently observed in those persons who have died of some other disease, and 
who have never suffered from venereal disorders. Farthermore, syphilis at- 
tacks such a great number of persons, it so frequently coincides with various 
organic lesions, that it is not surprising that some of them should have been 
considered as having been produced by it; but if it be certain, as Lancisi, Mor- 
gagni, and many other commendable authors have remarked, that the dis- 
eases of the heart and vessels have become more frequent since the fatal ap- 
pearance of syphilis; is it not to exaggerate its influence, to attribute so much 
to it in the production of those diseases; and, if organic lesions appear to have 
been less frequent before the appearance of the venereal disease, is it not rea- 
sonable to suppose that this circumstance may be attributed to the fact, that 
medical observers could not recognise those diseases so well at that time as 
they are able to do since; thanks to the progress of pathological anatomy* 
We do not wish to # deny the influence of the venereal virus in the production 
of certain organic lesions; but we can assure our readers, that the effects of 
this virus have been greatly exaggerated; especially relative to the develop- 
ment of the vegetations and excrescences of the valves. Our opinion will 
appear so much the more probable, as the numerous vegetations observed on 
the skin, and the orifices of the mucous membranes, are frequently of so 



Xlviil INTRODUCTION. 

its tissue, more or less, we conceive, with difficulty, 
how it happens that the heart, of all the organs of 
the body, is the one most frequently disordered. 
And, without speaking of the purely sympathetic af- 
fections of the circulating centre, how numerous are 
its proper, essential or primitive, diseases ! Its various 
tissues become inflamed, isolately or simultaneously; 
its fleshy substance becomes relaxed or contracted, 
softened or condensed, thinned or thickened, and 
sometimes bursts; its cavities are found dilated or con- 
tracted; its orifices are sometimes enlarged, or be- 
come the seat of a contraction which is opposed to 
the free passage of the blood: this fluid coagulates in 
its cavities, and the fibrinc, concreting into globules, 
becomes elongated or tubular, and produces those va- 
rious concretions, known by the name of polypi of the 
heart, and to which the ancients attributed so great 
a part in the various diseases of that organ; finally, 
the fluid secreted after inflammation, becomes, in its 
turn, a cause of disease, after having been the effect. 
Its concreted and organized portion floats in the pe- 
ricardium, is deposited on its surface, is flattened into 
the form of membrane, forms layers more or less thick, 
which unite the corresponding surfaces of the peri- 
cardium, or forms rough villous products which the 
ancient authors mistook for hair, and which have 
given origin to the fabulous stories about hairy hearts. 
But enough has been said on a subject which we pro- 
pose to consider hereafter in all its details: let us re- 
turn, then, to the object of this introduction, and pass 
on to the second part. 

doubtful, syphilitic character, that they frequently resist anti-venereal treat- 
ment, and can only be removed by excision. 



INTRODUCTION. xlix 



PART II. 

HISTORICAL SKETCH OF THE DISEASES OF THE 

HEART. 

If it be true, that pathological anatomy and phy- 
siology are the great luminaries of medicine; and, if 
it be true, that without them, this science would lan- 
guish in eternal obscurity; it is not amtng the phy- 
sicians of antiquity that we are to find any positive 
knowledge.respecting the pathology of the heart and 
the aorta; since the civil, political, and religious laws 
of the Greeks and Romans, prohibited, under severe 
penalties, the dissection of human bodies.* The an- 
cient physicians, therefore, could only have known 
the external and general phenomena by which those 
diseases are manifested: as these phenomena, how- 
ever, are common to many other pathological affec- 
tions, they would be led, necessarily, to confound the 
latter with the former; which they, in fact, did; un- 
der the vague and generic term asthma or dyspnoea. 
This confusion prevailed even for a long time after 
that pathological anatomy had begun to be cultivated; 
and this was inevitable, for asthma is, in fact, the pre- 
dominating symptom of all the severe diseases of the 

* The Egyptians have had some anatomical notions respecting the dis- 
eases of the heart; which will not be at all surprising to those who are ac- 
quainted with the fact, that anatomy was cultivated in Egypt, where the 
kings themselves, according to Pliny, dissected bodies, with a view of stu- 

G 



1 INTRODUCTION. 

thoracic viscera. Lancisi* and Morgagni,f had 
clearly perceived, that the diseases of the heart fre- 
quently determine symptoms, which the physicians 
of that day inconsiderately referred to the affections 
of the pleura and lungs; a mistake which many practi- 
titioners committed even in the time of Corvisart, and 
which is, perhaps, even committed in our own days, 
as well as the error of an opposite description. 

The long ages of barbarism, which succeeded the 
fall of the Roman empire, were the iron ages of me- 
dicine, in general, and of anatomy, and pathological 
physiology, in particular. We are not indebted to 
them for a s^igle idea of any importance respecting 
the diseases of the heart and large vessels. 

The Arabs, among whom medicine, exiled from 
Europe, found a temporary refuge, did not add any 
discovery worthy of being mentioned in the history 
of these diseases. It was not until some time after the 
revival of letters in Europe, that facts, relative to 
the organic lesions of the heart, were collected; but 
while the physicians of antiquity were only able to 
observe the external phenomena of these lesions, 
most of the observers of the fifteenth or sixteenth 
century, on the contrary, did not even mention the 



dying diseases: "Ab regibus quoque corpora mortuommad scrutandos mor- 
bos insecabantur. (Nat. Hist, i. xix. c. 5.) 

* " Occulta multorum malorum causae sunt investigandae quae ipsis cordis 
vasis dilatatis vel obstructis, repositae sunt. Nonnulla suffbcativa astmata, pec- 
toris hydropisis uno ex fonte pendent, inaequalibus videlicet vasis cordis." — 
(Lancisi, de Motu Cordis, &c.) 

j- Morgagni, speaking of the various causes of dyspnoea, says, " Earum 
precipuae et saepius quam aliqui putant, aut ad aquam spectant effusam, aut 
ad cordis, majorumque vasorum dilatationem." We shall presently see that 
the opinions of Lancisi and Morgagni are incorrect. 



INTRODUCTION. H 

symptoms of those alterations of the heart, which they 
had discovered in their anatomical researches. Their 
labours, too, were almost destitute of any thing fa- 
vourable to the progress of medicine. Baillou, who 
first employed the expression aneurism to distinguish 
dilatation of the heart, is almost the only one to whom 
the reproach, of having neglected to relate the phe- 
nomena connected with the lesions of the heart which 
he had observed, does not apply. Lancisi, Valsalva, 
and Albertini, the worthy successors of Vessalius, Ni- 
cholas, Massa, of Charles Etienne, de Baillou, and 
others, contributed much to the treasures of science, 
by their valuable researches. Lancisi established, 
for a symptom of the dilatation of the right cavities, 
the pulsations of the jugular veins, and he consecrated 
the expression aneurism, which Baillou had already 
employed to distinguish the dilatation of the heart. 
Valsalva and Albertini have rendered themselves fa- 
mous, by the method which they proposed for the 
treatment of aneurism, which yet retains their names. 
Worthy inheritor of the observations of his master, 
and possessing a greater number, which he had col- 
lected himself, the celebrated Morgagni, the father 
of pathological anatomy, consecrated to the history of 
the diseases of the heart, the whole of his 17th and 
18th Epistles, and many other portions of his immor- 
tal work. He brought to the study of these diseases 
that profound sagacity, that admirable penetration, 
that spirit of analysis and luminous discussion, which 
will for ever ensure him the first rank among the most 
illustrious of the medical profession. The work of Se- 
nac, on the structure and diseases of the heart, pre- 
sents us with a complete picture of all the knowledge 



Hi INTRODUCTION. 

up to that time, on this branch of pathology; and 
that work, honoured with the suffrage of Morgagni, 
will remain, for a long time, among the number of 
classic works. 

About the commencement of the present century, 
however, an illustrious physician reconstructed, for 
the most part, the edifice raised by Senac. Rich 
with the observations of his predecessors; rich in his 
own observations; richer yet in his genius, and in that 
wonderful sagacity with which nature had so liberally 
supplied him, Corvisart, the Morgagni of France, 
composed, under the modest title of U Essai sur les 
Maladies et les Lesions Organiqnes da Ccear et des 
gros Vaisseaux" a work for which he deserves the 
praise of all medical Europe. Since then, Testa, in 
Italy, Burns, in England, Kreysig, in Germany, have 
published works which have not thrown into shadow 
the work of Corvisart, although these authors have 
really diffused new light on these diseases. They 
have, especially, explained the effects of inflamma- 
tion on the various changes of structure met with in 
the heart or the great vessels. Finally, in these lat- 
ter times, M. Laennec, by means of the ingenious 
method of exploration which he has discovered, has 
brought to the diagnosis of the diseases of the heart, 
a light which none of his predecessors were able to 
throw around it. Notwithstanding the labours of 
these celebrated physicians, the subject has not been 
exhausted: it remains to determine more precisely, 
by numerous facts, the various forms of hypertrophy 
and dilatation of the heart, for the division into ac- 
tive and passive aneurisms, proposed by Corvisart, is 
far from embracing the whole of them; to clear up, by 



INTRODUCTION. liii 

the light of analysis and physiology, the various phe- 
nomena, which attend the several diseases of the 
heart; it remains to discriminate from among the ge- 
neral symptoms which have been assigned indiffer- 
ently to all these diseases, those which appertain to 
any particular one; it remains to dissipate the gross 
errors which authors have committed in this respect; 
it remains to ascertain the best method of distinguish- 
ing them, that we may not confound, as has been for 
a long time done, a lesion, purely symptomatic, with 
the principal and essential disease; and not to take 
the effect for the cause; it remains to inquire into the 
true nature of the numerous anatomical alterations 
of diseased organs, and to study the effect of in- 
flammation in the production of such alterations; 
finally, it remains to establish the proper method of 
treatment for those diseases which Corvisart regarded 
as necessarily mortal; which he would not have con- 
sidered as such, had he possessed more precise ideas 
respecting their nature, and the surest means of as- 
certaining their origin. Such are the deficiencies we 
have attempted to supply in the work at present pub- 
lished; happy should our efforts not be entirely lost, 
either to science or humanity. 



TREATISE 



DISEASES OF THE HEART, &c. 



BOOK FIRST. 

ON THE DISEASES OF THE AORTA. 

GENERAL OBSERVATIONS. 

The works lately published on the diseases of the 
blood vessels, whether in France, Italy, England, or 
Germany,* have undoubtedly much improved our 
knowledge of this important part of medical doctrine. 
We can say, however, without the fear of being con- 
tradicted, that science yet stands in need of a good 
monograph on inflammation of the vascular system, 
and of the aorta in particular. In fact, many authors, 
while describing, with sufficient exactness, the vari- 
ous anatomical changes met with in the aorta, have 
paid no attention to the important influence of in- 
flammation in their production. This deficiency we 
shall endeavour to supply. We shall, therefore, be- 
gin with the history of the inflammation of this great 
artery, including the inflammation of the internal 
membrane of the heart and pulmonary artety, which 
so frequently accompany it. We shall endeavour to 

* See the works of M. M. Corvisart, Laennec, Scarpa, Burns, Hodgson, 
Kreisig, &c. 

3 



18 DISEASES OF THE AORTA.. 

prove that most of the pathological alterations of these 
parts noticed by authors, are really the consequence 
of either an acute or chronic inflammation of their 
texture. However, as some of these lesions are them- 
selves the true causes of disease, or, rather, of them- 
selves constitute the diseases, we think it will be best 
to make several divisions of the subject. In the first 
chapter, we shall treat of inflammation of the aorta, 
internal membrane of the heart, and pulmonary arte- 
ry, with their effects; for example, redness, effusion 
of coagulated lymph, thickness or hypertrophy of the 
parts affected, ulcers, perforations, atheromatous, 
cartilaginous, calcareous, earthy^ and tubercular for- 
mations. In the second chapter, we shall take up the 
subject of aneurism of the aorta, and its varieties: 
we shali then investigate the relations which subsist 
between this disease and aortitis : the third chapter 
shall be devoted to the contractions of the aorta; and 
the fourth will be appropriated to the investigation 
of the indurations and vegetations of the valves, and 
the contractions of the orifices of the heart. 



DISEASES OF THE AORTA. 19 



CHAPTER I. 

ON INFLAMMATION OF THE AORTA, INTERNAL MEMBRANE OF THE HEART, 
AND PULMONARY ARTERY] AND ITS CONSEQUENCES, SUCH AS ULCERS, 
PERFORATIONS, CARTILAGES, AND CALCAREOUS DEGENERATIONS, &c. 

Aortitis must be considered the principal sub- 
ject of this chapter, although we shall include in one 
view these three phlegmasia, because they are situ- 
ated in a continuous system, and often exist together. 
Now, inflammation may affect separately or simulta- 
neously the three membranes of which the aorto is 
composed, and the cellular tissue which unites them 
reciprocally with each other : it seems, however, to 
manifest an unfortunate preference for the internal 
membrane ; either because it is more immediately ex- 
posed than the rest to irritating causes, or because 
its striking analogy with serous membranes peculiarly 
disposes it to inflammation. 

In the first article we shall present some cases of 
acute and chronic phlegmasia of the aorta, and in the 
second we shall trace the general picture of the dis- 
ease. 



ARTICLE I. 

Observations on the Phlegmasia of the Aorta, Internal Membrane 
of the Hearty and Pulmonary Artery. 



1st, Observations on Acute Aortitis, and Phlegmasia of the Internal Mem- 
brane of the Heart. 

Case I. — A man who had just returned from Ja- 
maica, where he had sufFered' severely from dysen- 



20 DISEASES OF THE AORTA. 

tery, was attacked with violent pneumonia, which, 
in five days, brought him to the grave. The cavi- 
ties of the pleura contained a large quantity of lymph 
and serum; the pericardium was covered with lymph; 
the cells of the lungs contained a bloody serum, and 
the bronchise were much inflamed. All the thoracic 
viscera bore traces of acute inflammation the most in- 
tense, which had also extended to the aorta, the in- 
ternal membrane of which was of a deep red colour, 
and presented an effusion of coagulable lymph in its 
cavity. The effused lymph was closely united to the 
internal membrane, and part of it had passed even into 
the left subclavian, which was almost entirely oblite- 
rated. 

This case, taken from the excellent work of Mr. 
Hodgson on the diseases of the arteries and veins, is a 
very remarkable example of acute aortitis. The same 
author has had some other opportunities of observing 
this disease, particularly in a case where the ligature 
of the femoral artery, after amputation, produced in- 
flammation of the internal membrane of this vessel, 
which extended even to the heart. He relates that 
the same accident had been observed in analogous cir- 
cumstances by Messrs. Cline and Abernethy. Ob- 
servers, until lately, have paid but little attention to 
this disease of the aorta. Nevertheless, Boerhaave 
and Morgagni* make mention of it without having 
had a very correct idea of its nature. M. Portalf 
has, likewise, observed the same disease in a young 
man who died some days after the recession of an acute 
eruption: the thoracic aorta was very red, swollen, soft, 
and its internal membrane, near the diaphragm, much 

* Morgagni, Lib. ii. Epist. JLnat. Medica. xxvi. art. 36. 
f Course (FJlnatomie Medicale, torn. iii. p. 127. 



DISEASES OP THE AORTA. 21 

swollen and softened. MM. Franck, Corvisart, Laen- 
nec and Recamier, have also collected some cases of this 
pathological condition. Mr. Hodgson endeavours to 
establish a difference between redness of the inter- 
nal membrane of the aorta, observed by these last au- 
thors, and that which occurs in acute aortitis. But 
it seems to us that Mr. Hodgson has not presented 
any conclusive proof in support of his opinion. M. 
Laennec, also,* while he allows that some doubt at 
present exists respecting the nature of this redness, 
is disposed to regard it as inflammatory : such is also 
the opinion we have formed, an opinion the truth of 
which seems to be demonstrated by the numerous cases 
we are about to offer. 

Some of the numerous observers, whom we shall 
cite in the present work, in speaking of the redness 
or phlogosis of the internal membrane of the aorta, 
have not observed the analogous state of the internal 
membrane of the heart. f This silence would have 
been rather surprising, if we had not known with 
what facility this lesion, on which we had not fixed 
our attention might be unveiled to observation: the 
lesion of which we are speaking is, however, very 
frequently accompanied with redness of the aorta, as 
we shall presently prove by facts. We are not igno- 
rant that other physicians have observed this redness 
of the internal membrane of the heart, and among 
others, we shall quote Dr. Baillie, who has seen the 
valves of the veins affected with real inflammation 
and covered with coagulable lymph. 

* There is a species of redness, of which we shall presently speak, which 
M. Laennec does not think of an inflammatory nature. 

f M. Laennec mentions this redness of the internal membrane of the heart 
and pulmonary artery. 



22 DISEASES OF THE AORTA. 

Case II. 

Redness and Albuminous Exudation of the Internal Surface of the 
Aorta. (Aortitis.) 

George Andrew Steller, thirty-seven years of age, 
cooper, of a strong but highly lymphatic constitution, 
had been sick five or six months, when he entered 
the hospital at Cochin, the 5th of October, 1823, in 
the following state. Orthopncea, oppressed breathing 
on the least motion, and while lying on the right side; 
pulse scarcely perceptible in the left arm; vibrating, 
strong, regular, unfrequent in the night: leucophleg- 
masia. The pulsations of the heart calm and regular; 
those of the ventricles prompt, those of the auricles 
slower, accompanied with a slight rustling sound 
which is not continuous: both of them heard in the 
whole left side, and to a great extent in the right. 
Respiration strong, puerile, accompanied with a mu- 
cous and sibilant rattle in the whole right and supe- 
rior part of the left side; egophony manifestly existing 
in the lower part of this last, more developed than 
the former, which gives a low flat sound. Diagnosis. 
Hydro-thorax of the left cavity, hypertrophy of the 
heart. 

Notwithstanding the employment of bleeding, blis- 
ters, aperients, digitalis, &c, the patient died in the 
manner of individuals affected with hydrothorax, on 
the 22d of the same month in which he entered the 
hospital. 

Examination of the Body thirty-six hours after Death. 
Each cavity of the chest contained about a pint of 
serum, the left lung was pushed upward and backward 
by the effused fluid, and the heart, which was enor- 
mously hyptrtrophied. The mucous membrane of the 



DISEASES OF THE AORTA. 23 

bronchise was red, especially in the last divisions of 
the left. The pericardium was adherent to the heart 
by a false membrane, partly organized, and partly 
not; the aorta, of a natural caliber, was strewed, in 
the whole extent of its internal surface, with very 
small yellow distinct spots, not ossified, situated out- 
side the internal membrane, which was red and co- 
vered with a layer of reddish coloured albumen, about 
a third of a line in thickness. At the base of one of 
the aortic valves was observed a small osseous tuber- 
cle: the pulmonary artery and its valves presented 
nothing peculiar. — The gastro-intestinat mucous 
membrane was red and injected. The redness of the 
internal membrane of the aorta, the albuminous false 
membrane, with which it was covered, are two cha- 
racters, which do not permit us to mistake true in- 
flammation. We request the reader not to forget the 
results of the cadavenc autopsy of the two preceding 
subjects; we shall rarely henceforward meet with the 
plastic and albuminous epanchement just spoken of. 
The reason maybe easily conceived: the epanche- 
ment, as soon as formed, is found in contact with the 
current of the blood contained in the aorta, and must, 
of necessity, frequently be carried along with it, and 
leave scarcely any trace of its existence. 

We shall return, farther on, to the consideration 
of the small yellow spots situated underneath the in- 
ternal membrane of the aorta. 

Case III. 

Pleuro-Pneumonia: Phlegmasia of the Internal Membrane of 
the Heart and the Aorta. 

Antoinette Lamongeis, aged sixty-four, domestic, 
of a good constitution, entered the hospital Cochin the 



24 DISEASES OP THE AORTA. 

11th of April, 1822, saying she had been sick four 
days. She presented the symptoms of bilious pleura- 
pneumonia: violent headach and little delirium, vo- 
miting, tongue blood-red at the edges; yellow tint of 
the face, pleuritic stitch; sputa moulded; great op- 
pression; respiration almost extinct at the base of the 
chest, &c. Notwithstanding the employ of general 
and local bleeding, blisters, &c, the patient died on 
the fourth day after entrance. 

Examination of the Body thirty-six hours after death. 

We found a phlegmasia of the bronchia, pleura and 
lungs. 

The pericardium contained two or three spoonsful 
of a bloody fluid: it was less injected at the left, than 
at the right side, which corresponded with the side 
of the lung, most inflamed. The heart, of ordinary 
volume, was filled with blood partly liquid, and partly 
coagulated; the mitral valve was of a deep red colour; 
it was the same with the tricuspid, which was in a 
fungous state, and fixed to the walls of the ventricle 
by tendinous filaments. The aorta, at its commence- 
ment, as well as its valves, was red ; these were 
strown with small superficial ulcerations, and earthy, 
or fibro-cartilaginous concretions. 

In this case, we find, besides redness of the internal 
membrane of the aorta and the heart, the yellow spots, 
indicated in the preceding case, the first rudiments 
of the ulceration of that membrane certainly: with 
these signs, it is not difficult to recognise a phleg- 
masia ; and we may also add to these anatomical and 
positive proofs, the collateral evidence derived from 
the co- existence of an inflammation of the pleura, 
lung, and bronchial tubes. 



DISEASES OF THE AORTA. 25 



Case IV. 



Julie Martin, aged twenty-one, dressmaker, of a good 
constitution, was taken sick with a pleuro-pneumonia, 
eight days before her entry into the hospital Cochin, 
the 2d of June, 1822. General and local bleeding 
had been employed, without success; the patient sank 
about a month after the commencement of the phleg- 
masia. In the latter stage of the disease, the sputa 
exhaled an infectious and almost gangrenous odour. 

Examination of the Body — twenty-two hours af- 
ter death. The pleura and both lungs were inflamed: 
a gangrenous abscess was found in the right lung, &c. 
— The cavities of the heart contained large clots of 
blood, white on the exterior, rose colour within, and 
prolonged into the aorta and large vessels; the inter- 
nal membrane of the right cavities, and especially 
that part reflected on the valves, offered a brownish 
red colour: this colour was much less intense in the 
left cavities; the heart in other respects was well 
formed. — The pericardium contained a little turbid 
serum, in which were floating some thin shreds, de- 
licate as cobweb. 

Case V. 

Redness of the Internal Membrane of the Heart and Aorta 

(Aortitis. J 

Charles Dalmon, aged seventy-nine, married; of a 
strong constitution; had been sick fifteen days from 
the time he entered the hospital Cochin, 3d July, 
1822. He complained of pain in the abdomen, and 
a breath and mouth so fetid that he could hardly 
support the odour. Had been troubled with spon- 
taneous vomiting of bitter bile, and vomited the soup 

4 



26 DISEASES OF THE AORTA. 

and sweet wine which they made him take. Had a 
cough for a long time, and suffered from pulsations of 
the heart, when he took a little too much exercise. 
A high fever, he said, occurred every day at irregu- 
lar periods. However this may be, we observed on 
the day after his entrance at the evening visit, high 
fever, skin hot, headach, pulse frequent, strong and 
vibrating ; beatings of the heart very powerful ; desire 
for wine to support the strength. (Gum water elec- 
tuary, diet.) 

The fever continued with the same intensity the 
following days ; torpor soon occurred, and on the 
seventh blisters were applied to the legs. 

8th. The patient comatose; the left arm contracted, 
and in endeavouring to extend it, the patient makes 
slight groans, and mournful cries: the pulse preserves 
its force and frequency. Finally, on the 10th, the 
patient died after long continued rattles, and with 
symptoms, which announced cerebral congestion. — 

Examination of the Body, twenty -four hours after death. 

The meninges presented some traces of inflamma- 
tion; the case of the cranium and the ventricles con- 
tained a large quantity of reddish coloured serum, the 
cerebral substance was injected, and rather soft ; the 
stomach and small intestine were filled with green 
coloured bile, and presented red points. The four 
cavities of the heart, the aorta and the other large 
vessels contained a large mass of blood, partly liquid, 
and partly coagulated ; the texture of the heart was 
soft, flabby and brittle; the membrane which covers 
it, internally, was of a deep red, especially about the 
valves ; the internal membrane of the thoracic and 
abdominal aorta, was red, and strewed with osseous 



DISEASES OF THE AORTA. 27 

earthy layers. — The spleen, softened, broke down to 
mush, on the least touch; the liver, on the contrary, 
was of a black colour, and denser than in the natural 
state. 

We shall presently see that aortitis is accompa- 
nied with diseases of an evidently inflammatory na- 
ture; we shall now proceed to exhibit the same affec- 
tion in subjects who have died of idiopathic fevers. 

Case VI. 

AT AXO- ADYNAMIC FEVER. * 

Death nine days after entrance into the Hospital. — Redness of the 
Internal Membrane of the Heart and large Vessels; Intestinal 
Ulcers; Redness of the Bronchial Mucous Membrane, fyc. 

Virginie Aubart, twenty-one years of age, of a 
lymphatic temperament, was brought to the hospital 
Cochin the eighth of November, 1822. She was in a 

* The phenomena of the general system, and those which occur in par- 
ticular parts, or organs, will always be the subject of dispute between the 
exclusive physiologist and pathologist. The great mass of facts, collected 
of late years, concerning particular organs, will lead the pathologist to over- 
look the sympathetic and nervous phenomena of the animal frame ; while 
the physiologist may also err, by confining his attention to idiopathic or 
general disease. 

It occurs to us that the phenomena of fever, as well as of every other dis- 
ease, should be studied in reference to one whole and undivided system, in 
which, both general and local sympathies exist, and which must all form one 
clear and definite idea, before we can rightly understand the nature of dis- 
ease, or prescribe a remedy adapted to the general condition and want of the 
system. 

Without wishing to depreciate the just value of those writers who trace 
the phenomena of fever to particular organs, or of those who have sought 
for a perfect knowledge of the disease in the general affection of the system, 
we think the period has arrived when general pathological anatomy, or the 
general anatomy of the systems, (according to Bichat,) should be studied 
with the same ardour with which the pathological investigations of the com- 
pound organs have been pursued. 

Until this rich domain be thoroughly explored, we cannot expect to ex- 
plain the mysteries of pyretology. The interest of this subject has led us 



28 DISEASES OF THE AORTA. 

state of prostration and delirium, which did not per- 
mit her to give any account of the circumstances 
which preceded and determined her disease. The 
other principal symptoms observed, were the follow- 
ing: lips and teeth covered with a black crust; pale- 
ness of the face and tongue, which is dry, hard and 
apparently burnt; urgent thirst; pain and swelling in 
the parotid region; abdomen sensible and contracting 
on pressure; skin dry, discoloured and heated; pros- 
trate on the back; pulse much accelerated, small and 
weak; (140 pulsations in a minute,) delirium loqua- 
cious; picking of the bed-clothes; cough frequent 
with rumbling mucous rattle. (Blisters to the legs, 

thus far away from the principal object of our remarks, which was to give 
concise definitions of the several fevers mentioned by the French authors. 

From the earliest period of medicine the morb.d state of fevers of intense 
excitation has been characterized by symptoms of inflammation only, or by 
inflammatory symptoms allied with a superabundant secretion of bile or mu- 
cus. The progress of observation has led to the discovery, that the excita- 
tion is much increased, sometimes in the stomach, somet.mes in the secretory 
apparatus of the gastro-intestinal mucous membrane, which has led to the 
distinction of fevers into several kinds. Thus the angiotenic fever of the 
French authors is a sthenic disease, and consists of pure inflammatory irrita- 
tion of the vascular system, disconnected with any other disease, or affection 
of any particular organ, and is synonymous with synocha. The meningo- 
gastric fever is accompanied by b.lious phenomena, and depends upon an 
irritation of the mucous membrane of the digest.ve organs. The adeno- 
meningeal or mucous fever is attended with the same phenomena, but modi- 
fied by increased mucous secretions. 

The adynamic fever is an asthenic disease or synochus, attended by putrid 
phenomena produced Ly some change in the properties and qualities of the 
blood. The ataxic fever is the etfect of a cerebral or cerebrospinal irritation, 
and is the slow nervous or malignant fever of the old English writers. 

These terms designate all the varieties of febrile diseases, excepting the 
hectic, but they may all be more or less complicated; hence we have the 
expressions of inflammatory gastric (or causus of the ancients,) gastro-ady- 
nam.c, and mucoso-ataxic fevers, besides the gastro-adynamo-ataxic, the mu- 
coso-adynamlc-ataxic, and the ataxo-adynamic, which embraces all the symp- 
toms of that remarkable variety called typhus. 

c. w. c. 



DISEASES OF THE AORTA. 29 

sweetened gum-water, diet.) — The blisters produced 
no effect. — The patient died in the ataxo-adynamic 
state, on the 17th, nine days after his entrance. 

Examination of the Body twenty-three hours after death. 

External appearances. — Cadaveric rigidity; mus- 
cles nearly of a natural colour; redness, injection and 
swelling of the cellular texture, and of the sub-max- 
illary ganglions; infiltration of the left abdominal ex- 
tremity. 

Circulatory and Respiratory Organs. — On each 
side of the thorax the visceral pleura adheres to the 
parietal by a soft and recent cellular layer. Both 
lungs are crepitant, pale anteriorly, red and swollen 
posteriorly; the mucous membrane of the air passages 
is red and injected; the pericardium contains a good 
deal of red-coloured serum; the heart is well formed, 
but a little soft and flabby; its cavities are filled partly 
with liquid, and partly with coagulated blood; their 
internal membrane, especially of the right cavities, is 
red; the aortal valves, the internal surface of the aorta 
and the branches going from it, present a beautiful 
scarlet colour, which is not owing, at least in appear- 
ance, to vascular injection, but seems rather a kind 
of stain: the same colour is observed, also, in the pul- 
monary artery and its valves. The internal mem- 
brane, of the venous system generally, is of a brown- 
ish red. The deep-seated veins of the abdomen are 
infiltrated and obstructed by a long fibrinous clot, 
which is solid, has existed a long time, and extends as 
far as the origin of the vena cava. 

Digestive Organs. — Externally the stomach and 
intestines are very white, excepting that various red 
patches, corresponding to internal ulcers, may be ob- 



30 DISEASES OF THE AORTA. 

served upon the convolutions of the small intestine. 
The spleen is twice as large as in the natural state, 
of a very soft texture and reddish brown colour, 
which becomes red on exposure to the air; the liver, 
rather large, is, in other respects, healthy. — The 
stomach and small intestine contain a great quantity 
of bile, which has deeply coloured their mucous mem- 
brane : this, in the stomach, presents superficial red 
points; in the duodenum, and beginning of the jeju- 
num, it is pale, but as we advance towards the coe- 
cum appears deeply injected, and of a red colour. 
Many ulcers are disseminated about the end of the 
jejunum and commencement of the ilium, where no 
trace of the injection can be found. Towards the 
termination of the ilium, the ulcers are more nume- 
rous, extensive and deep; they have destroyed a large 
portion of the ileo-coecal valve; around many of them, 
may be observed small ulcers and whitish coloured 
granulations. The coecum, and ascending colon, 
present also numerous ulcers, and thin mucous mem- 
brane, is, for the most part pale, in which appear 
small, white, or reddish pustules, which give it a 
knotted and speckled appearance. There is in the 
coecum, also, a large opaque spot, which appears to be 
a cicatrix. The arch of the colon, its descending 
portion, its sigmoid flexure, as well as the rectum, 
are contracted, and contain some rather solid, fcecal 
matter, but present nothing except a slight rosy tint. 
The mucous membrane of the pharynx and oesopha- 
gus is pale. — The mesenteric ganglions are red and 
swollen. 

Encephalic 0?*gans. — The cerebral membranes are 
a little infiltrated, especially at the convexity of the 
cerebrum, where they are white and lacteous. We 



DISEASES OF THE AORTA. 31 

find a small quantity of serum at the base of the cra- 
nium, and in the ventricles; the texture of the brain 
is rather soft, and evidently injected. 

Among the numerous organs which have offered 
us manifest changes of structure, we have directed 
our attention particularly to such as have relation to 
the heart and the vessels. The internal membrane 
of these organs has presented to our view a redness, 
which seems to us a sufficiently positive character of 
its inflammation. We believe we shall be able to say 
as much of the softening and of the feeble adhesion 
and flaccidity of the heart. The changes above men- 
tioned, are not confined to the particular cases already 
observed, we have met with them in more than twenty 
individuals, who have died of acute or chronic idio- 
pathic fevers. We considered it our duty to relate 
the above case in detail. It will be sufficient for our 
present purpose, however, to mention such circum- 
stances as directly refer to our present subject, ob- 
tained from cases collected with the same exactness 
and attention. 

Case VII. 

Turpinat, a young man of twenty years of age, a 
mason by trade, of sanguine, bilious temperament, 
had been sick seven days before his entry to the 
hospital, the 20th May, 1822. He presented all the 
symptoms which constitute the ataxo-adynamic fever 
of authors. Leeches, blisters, and the usual methods, 
were employed without success. He died, fifteen 
days from the time he entered the hospital. 

On opening the Body, the heart was found flabby 
and soft, and the cavities somewhat enlarged. The 
internal membrane was found to be of a deep red 
colour. 



32 DISEASES OF THE AORTA. 

Case VIII. 

Georges Bousserat, twenty-six years of age, prin- 
ter, thin, pale, nervous, in other respects of a good 
constitution, had been sick eight days, when he en- 
tered the hospital Cochin, 3d September, 1822. He 
presented the symptoms of fever called ataxic: 
twelve days after his entrance he expired. The 
Body was examined twenty-four hours after death, 
and presented many changes, among which we shall 
notice only the following. The heart was well formed, 
but flabby, the texture rather soft, and the internal 
membrane of a reddish brown colour. 

Case IX. 

Lewis Francois Grape, twenty-four years of age, 
water-carrier, of a sanguine bilious temperament, 
had been indisposed for a month, and kept to his bed 
three days, when he was brought to the hospital Co- 
chin the 14th of July, 1822. He was affected with 
the adynamic fever of authors; notwithstanding the 
employment of antiphlogistics, he died the sixth day 
after entering the hospital. The Body was ex- 
amined twenty-six hours after death. The heart 
was flattened, flabby and almost empty, the valves 
reddish brown; the internal membrane of the aorta 
rose-coloured. 

Case X. 

Jacques Blater, of a strong constitution, thirty years 
of age, had been sick fifteen days before he entered 
the hospital Cochin, on the 16th October, 1822. He 
died, at the end of twelve days, of a fever similar to 
the preceding; accompanied, however, with ataxic 
and phrenitic symptoms, so violent as to resemble 



DISEASES OF THE AORTA. 33 

spasms of hydrophobia. Body examined thirty-six 
hours after death: heart well formed, robust and firm, 
containing some liquid and black blood. Internal 
membrane of the cavities of a brownish colour, &c. 

Case XI. 

Genevieve Brule, 22 years of age, married, of a 
good constitution and regular habits, brunette, — had 
been sick for fifteen days, but was confined to the bed 
only nine, when she entered the hospital Cochin, 
25th June, 1822. She died in the course of twenty- 
five days, with symptoms of ataxo- adynamic fever. 
Body examined twenty-two hours after death. Heart 
remarkable for its extreme flaccidity, walls of the 
left ventricle very soft, and, as soon as they were cut 
into, flattened down. Internal membrane red, as well 
as that of the aorta. We shall confirm the opinion 
we have entertained of inflammation of the internal 
membrane of the heart and large vessels, by several 
cases of acute disease, denominated, by some, idiopa- 
thic fever, and by others gastro-enteritis; we have ob- 
served in these cases softening and a remarkable flac- 
cid state of the heart's structure. We shall now ad- 
duce some new cases of the same disease, coinciding 
with inflammation of the most important organs. 

Case XII. 

Martin- Jean-Louis Plouquet, thirty-seven years of 
age, of a good constitution, entered the hospital Co- 
chin the 9th of January, 1822, and said he had been 
sick for three months. He presented slight symp- 
toms of peritonitis; but, on the fourth day after his 
entrance, became most alarmingly ill, and died the 

5 f 



34 DISEASES OF THE AORTA. 

night following. Autopsy thirty hours after death. 
Many traces of severe peritonitis, especially purulent 
depositions, in the abdominal cavity. The pericar- 
dium contained a large quantity of reddish serum. 
Internal membrane of the aorta of a beautiful red co- 
lour, which washing would not remove.* This co- 
lour resembled a tincture, and was not owing to the 
presence of injected vessels. 

The following is a case of phlegmasia of the inter- 
nal membrane of the heart and aorta, coexisting with 
symptoms of general congestion, and suppurative in- 
flammation of the liver. 

Case XIII. 

Jean Cogniasse, twenty-two years of age, brown 
compiexioned, strongly constituted, entered the hos- 
pital Cochin 30th of July, 1822. This patient came 
from the Hotel-Dieu, where he had been treated for 
an (Edematous erysipelas of the face, and cured by 
repeated purgatives. He had been bled some time 
before at la Petie, for malignant fever. At his entry 
we observed the following symptoms: Colic pains, 
copious watery discharges, pain in the right hypo- 
chondrium, ardent thirst, cough, flat sound and ab- 
sence of respiration at the lower part of the right side; 
depression, expression of anxiety, prostration, alter- 
nate chills and sweats. The most powerful antiphlo- 
gistics were employed without effect. The complex- 
ion became more and more yellow, and the patient 
died with symptoms very much resembling those of 
yellow fever. Autopsy twenty-four hours after death. 
Intestinal canal, and especially the arch of the colon, 

* After maceration in water for some time,, this colour was completely 
dissipated. 



DISEASES OF THE AORTA* 35 

enormously distended with gas; about two glasses of 
red liquid, almost purely blood, in the peritoneum, 
which is uniformly red, dry and somewhat viscous; 
five abscesses in the liver, with pultaceous softening 
of the substance surrounding the purulent depositions; 
the small intestine, uniformly injected, contains a large 
quantity of clotted and liquid blood, which has, in 
some measure, stained the mucous membrane red; the 
pleura is deeply injected, and infiltrated, in some 
parts, with blood; its cavity contains a little blood-co- 
loured serum; the mucous membrane of the bronchial 
vessels is in contact with a blood-coloured mucus of a 
deep red; the pericardium contains a moderate quan- 
tity of deep-yellow-coloured serum; the heart is vo- 
luminous and robust, of a soft flabby texture, and con- 
tains clots of blood, buff-coloured in the right cavi- 
ties, and black in the left: the membrane which co- 
vers these cavities, especially the left, presents a deep 
brown colour, which contrasts with the scarlet-red 
observed in the thoracic and abdominal aorta. 

In the following case the phlegmasia occupies only 
the internal membrane of the heart. 

Case XIV. 

Charles Gamier, fifty years of age, having suffered 
frequent catarrhal affections in the course of his life, 
entered the hospital Cochin the 26th of October, 
1822. He complained of cough, and had a rheumatic 
affection, and was on the point of departing when he 
was suddenly taken with angina-pharyngo-laryngia, 
to which he became a victim on the fifth day. 

Autopsy twenty hours after death. — Inflammation 
and suppuration of the pharynx, amygdalae, larynx 
and inferior half of the right lungj the pleura, espe- 



36 DISEASES OF THE AORTA. 

cially the right, offers chronic adhesions; the right 
portion of the pericardium is intimately united to the 
corresponding pleura, the pericardium is uniformly 
injected, that portion which covers the right side of 
the heart is strewed with white-coloured plots, thick- 
er on the auricle than the ventricle, easily detached, 
and are probably nothing more than false membranes; 
that portion w T hich covers the left side offers nothing 
similar, and what appears remarkable is, that the pe- 
ricardium of this side, exteriorly, does not adhere to 
the pleura-costalis; the heart is well-proportioned: 
the right cavities are distended with clots of blood, 
for the most part white, in which we may say the 
vessels begin to be organized; the internal membrane 
of the heart is red. 

It is not only in cases of inflammation, accompanied 
by acute fever, that we have had occasion to observe 
aortitis; we have met with it, also, in cases of inflam- 
mation and slow fever, of which we have numerous 
examples. 

Case XV. 

Marie Peraudin, twenty-two years of age, firmly 
constituted, entered the hospital Cochin on the 19th 
of August,! 822, about three months after confinement, 
presenting symptoms of the second stage of phthisis 
pulmonalis. In the mean while, pectoriloquy the 
most evident, soon declared itself in different points 
of the chest; and the patient, consumed by hectic 
fever, died, tranquilly, about two months and a half 
after she entered the hospital. 

JLutopsy thirty-six hours after death. — We shall 
lay aside in this case and the following, the description 
of the changes found in the thoracic and abdominal 



DISEASES OF THE AORTA. 37 

organs, and report only those which directly interest 
us here. No one can be ignorant, that the changes 
which the nature of this work obliges us to pass over 
in silence consist principally of tuberculated degene- 
ration of the pulmonary structure, tubercular ex- 
cavations, more or less numerous, and extensive ; and 
ulcerations of the mucous membrane of the intestines, 
&c. — Here is what we furthermore found in the 
young woman of whom we are speaking: the peri- 
cardium was adherent to the pleura, and contained a 
flocculent serum of a beautiful golden colour; it was 
injected, particularly that portion which covers the 
heart. The heart, well formed, but rather soft, was dis- 
tended by clots of blood, its internal membrane, princi- 
pally on the valves, offered a brownish red colour which 
intermingled, by a kind of gradation, with bright 
red and scarlet extended on the internal membrane 
of the aorta, where it was distributed in long stripes, 
prolonged into the coronary arteries, in those of the 
extremities and in the carotids, where it has gene- 
rally been less apparent. The cerebral arteries pre- 
served their natural colour; but the pulmonary artery 
and branches were red ; as well as the venous system 
in general. 

This redness did not seem to be owing to vascular 
injection: the cellular tissue surrounding the arteries 
and veins was red, and abundantly supplied with 
blood vessels ; and the red colour of its texture round 
the veins, increased the intensity of that of the in- 
ternal membrane. 

Case XVI. 

Josephine Mottier, forty-five years of age, widow, 
thin, and feebly constituted, was in the last stage of 



38 DISEASES OF THE AORTA. 

pulmonary phthisis when she entered the hospital 
Cochin the 10th of September, 1822. She enter- 
tained great hopes of recovery, and scarcely thought 
herself sick. Death occurred on the eighteenth day 
after she entered the hospital. 

Examination of the Body forty-eight hours after death. 

The heart is rather larger than the fist, and its 
texture is soft, flabby and easily torn; its internal 
membrane, is red, as if it had been soaked in blood; 
the valves are of a deep brownish red colour. 

Case XVII. 

Peter Canut, tailor, twenty-four years of age, large, 
lymphatic and feebly constituted, entered the hospital 
Cochin the 27th July, 1822, with symptoms of phthi- 
sis pulmonalis, of which he died in six weeks after 
entrance. 

Examination of the Body thirty hours after death. 

The heart about the size of the fist, was pale, and 
had a milky appearance on its external surface ; the 
internal membrane of the aorta was of a scarlet 
colour. 

Case XVIII. 

Jean Nicholas Mougenot, aged thirty-one, died at 
the hospital Cochin of phthisis pulmonalis, the 17th of 
August, 1822. At the opening of his body, we found 
pleuritic false membranes, tubercles, pulmonary ex- 
cavations, &c. The internal membrane of the heart, 
especially about the valves, was of a violet red 
colour.* 

* See this case more in detail, in No. 90. 



DISEASES OF THE AORTA. 39 



Case XIX. 



Marie Jean Jobin, aged sixty-five, entered the hos- 
pital Cochin on the 5th of December, 1822. She was 
affected with phthisis pulmonalis, which appeared 
to us complicated with disease of the heart. She 
died seven days after entrance. 

Autopsy. The lungs were crowded with tubercular 
granulations almost purulent. The internal membrane 
of the bronchia and pulmonary vessels is of a deep 
dull red. The heart is wrinkled, and the right 
cavities, as well as the pulmonary artery, offer 
a deep red colour, almost black in the right auricle ; 
the red colour exists in a less degree in the left cavi- 
ties : this colour passes insensibly to a yellow tint in 
the aorta. 

Case XX. 

Redness of the Valves of the Heart and internal Surface of the* 

Aorta. 

Jean Baptiste Grente, aged thirty- eight, glover,, 
entered the hospital Cochin on the 14th of November,, 
1822; appears very feeble. She was attacked with 
phthisis pulmonalis, and died about three weeks after 
entering the hospital. Ten hours after death the body 
was examined. The heart was smaller than the fist^ 
the cavities for the most part were well proportioned; 
the valves presented a red colour ; the internal mem- 
brane of the aorta was of the same colour in a les& 
degree. 

Case XXI. 

Jean Blin, aged twenty-one, seamstress, had been 
brought to bed about four months, and entered the 



40 DISEASES OF THE AORTA. 

hospital Cochin on the 12th of March, 1822, af- 
fected with a congestive abscess, complicated with 
phthisis pulmonalis; she died the third month after 
entrance. 

Autopsy thirty hours after death. Heart of na- 
tural size, texture soft ; aorta and large vessels con- 
tain coagulated blood; internal membrane of the heart, 
especially at the orifices, of rather a deep red. 

Case XXII. 

Bright red colour of the internal membrane of the 
aorta. — Jaques Bouelo, aged 20, attacked with phthi- 
sis pulmonalis, entered the hospital Cochin 20th 
March, 1822, and died at the end of five weeks. 
The heart and origin of the aorta contained clots of 
blood. The internal membrane presented a bright 
red colour. 

Case XXIII. 

Etienne Salmer, aged twenty-five, gardener, had 
arrived to the last stage of phthisis, when he entered 
for the second time the hospital Cochin, the 18th of 
April, 1822. He died five weeks after. Among a 
great number of pathologic lesions, presented on open- 
ing the body thirty hours after death, we remarked, 
that the internal membrane of the aorta immediately 
beneath the sternum, was of a bright red, almost 
scarlet. 

Case XXIV. 

Catherine Neven, aged forty-two, cotton dealer, a 
strong constitution, affected with phthisis pulmonalis 
in the advanced stage, entered the hospital Cochin 
the 20th of May, 1§22. Fifteen days after, she died. 



DISEASES OF THE AORTA. 41 

Examination of the Body forty hours after death. 

Lungs tuberculous* Heart gorged with blood, 
flabby and soft, its parietes thinned and its cavities 
dilated, especially the left ventricle. The internal 
membrane, which covers them, presents a deep red 
colour, which extends to the origin of the aorta and 
its valves, is not removed by repeated washing. This 
is observed as far as the abdominal aorta. The peri- 
cardium contained several ounces of reddish serum. 

We shall now proceed to give a rapid sketch of the 
symptoms presented by this disease. We shall bare- 
ly notice such as have no immediate connexion with 
the subject, such as hemoptysis, purulent expectora- 
tion, rale with ebullition of air, pectoriloquy, nausea 
and relax. We were struck with the violence of the 
fever in a case of this kind, that is to say, a case of 
phthisis. 

This fever had all the characters of that known un- 
der the name of inflammatory or angiotenic fever; burn- 
ing heat of the skin, although moist; pulse frequent, 
developed, rather soft; the face was of a bright red, 
the head painful, and we observed a slight delirium: 
the thirst was inextinguishable, the patient complained 
of intense pain under the sternum, and in the epigas- 
tric region, in consequence of which twenty leeches 
were applied. The pain was moderated; but the 
fever and delirium, with trembling in the muscles of 
the limbs, injection of the face and eyes, remained: 
lastly, the pulse, though frequent, lost its force, the 
face had sunk, and the patient died on the fifteenth 
day. 

The whole of the symptoms were certainly not such 
as are usually observed in pure and simple phthisis. 

6 



42 DISEASES OF THE AORTA. 

We have not the least doubt they should be referred 
to a phlegmasia of the internal membrane of the ar- 
teries which we have confirmed by autopsic exami- 
nation. This fact is very important, and goes to 
support the opinion of those who have attributed the 
inflammatory fever to a phlogosis of the vascular 
system, and accords perfectly with that of the cele- 
brated Austrian physician P. Frank, who assigns, as 
the symptoms of acute aortitis, a considerable throb- 
bing of the arteries of the head, a painful sensation in 
the course of the aorta, and a state of agitation and 
continual anxiety. 

Case XXV. 

Hectic Fever; Pulmonary Tubercles — Death: Redness of the In- 
ternal Membrane of the Heart. 

Toupaint Brule, twenty-seven years of age, grocer, 
of a delicate constitution, had taken cold more than 
eight months previous to his entry to the hospital Co- 
chin, July 2nd, 1822; he left the Hotel-Dieu, where 
he had for five days, he said, a burning fever, with 
delirium and agitation; he had suffered repeatedly 
from haemoptysis. However this may be, at his entry 
he presented symptoms of advanced phthisis pulmo- 
nalis, and particularly a pectoriloquy, very evident 
in the whole superior part of the thorax. The pulsa- 
tions of the heart were dull and developed; the fever 
was very high, and we could scarcely count the pulse, 
which was very quick and rather developed; (pecto- 
ral mixture, broth, &c.) On the 3rd, the patient had 
an haemoptysis, after a warm dispute with one of his 
parents. The 4th, the face was entirely decomposed, 
and death took place on the 5th^ at six in the morn- 
ing. 



DISEASES OF THE AORTA. 43 

Inspection of the Body thirty hours after death. 

Tubercles and pulmonary excavations, chronic 
false membranes, &c. — The texture of the heart is 
soft and flabby ; the internal membrane of its cavities 
is of a deep red; the left ventricle is dilated. 

The reflections at the end of the preceding case 
would apply, for the most part, to this; therefore they 
need not be repeated. 

Case XXVI. 

Almost Gangrenous Softening of the Heart, Redness of its Inter- 
nal Membrane and that of the Aorta. — Tendency to Syncope, 
Irregularity of the Pulse, sudden Death. 

Jean Louis Poismule, aged forty-two, stamp-worker, 
large, brown, and strongly constituted, presented 
symptoms of phthisis pulmonalis for nearly six 
months, when he entered the hospital Cochin, the 
24th of June, 1822; then breath very short, oppres- 
sion, difficulty of breathing, syncope on the least mo- 
tion; pain in the chest, extreme weakness, oedema of 
the malleoli, wasting, night-sweats, skin dry, hot fe- 
ver, pulse very frequent, rather developed, but soft 
and without resistance; pulsations of the heart soft, 
moderately sonorous, (pect. tinct. quart.) The fol- 
lowing days were not marked by any extraordinary 
symptom, except extreme irregularity and intermit- 
tence of the pulse. On the 3rd of July, at midnight, 
the patient was rather unexpectedly found dead in his 
bed. 

Autopsy thirty-five hours after death, (putrefaction 
of the body already well marked.) Marasmus was 
not yet much advanced; lungs adherent in every di- 
rection, filled with tubercles and large excavations. 
A considerable portion of their texture was soft and 



44 DISEASES OF THE AORTA. 

almost putrid. The heart voluminous, soft, flabby, of 
a brownish colour, as if it had already begun to pu- 
trefy; had its cavities dilated : the internal membrane 
which lines them was red; that of the aorta offered a 
deep red poppy colour. — The pericardium contained 
a red serum; the vessels contained a brownish and al- 
most decomposed blood; gas, the effect of commencing 
putrefaction, was found in almost every part, and the 
whole body was enormously swelled. 

It is not probable that the patient, in this case, 
died of phthisis pulmonalis. We know very well 
that the peculiar property of this disease is to con- 
sume, to reduce to the last stage of marasmus its nu- 
merous victims; but our patient was very far from 
having yet arrived at extreme emaciation: he pre- 
served, on the contrary, a good degree of flesh. Re- 
mark, lastly, that this man died suddenly, which is 
not unusually the case in phthisis. To what lesion, 
then, must we attribute this kind of anomaly, or rather, 
these incidents out of the common course of disease? 
We think this lesion is precisely the one we have 
met with in the heart and aorta; that is to say, phleg- 
masia of these organs: by it you can account for the 
tendency to lypothymia, the intermittence and irre- 
gularity of the pulse. 

We shall not enlarge on this subject; because the 
reflections arising from it would be more appropri- 
ately placed in the chapter on inflammatory softening 
of the heart. 

We could add some other cases to those we are 
about to relate; but we shall reserve them for other 
parts of this work, when we shall be careful to relate 
every thing which has any connexion with the sub- 
ject under consideration. 



DISEASES OF THE AORTA* 45 

Before making any observations on the cases rela- 
tive to chronic inflammation of the aorta and internal 
membrane of the heart, we shall present some new re- 
flections on those which precede. 

We have regarded all the cases of redness we have 
related as being traces of inflammation. Some per- 
sons will not agree with us perhaps respecting the na- 
ture of this redness, and consider it entirely indepen- 
dent of the inflammatory state : we will acknowledge 
we have been ourselves, for some time, disposed to 
embrace the latter opinion, from the circumstance 
that this redness is not owing to vascular injection, 
nor is the membrane always thickened; but the fol- 
lowing considerations almost compelled us to adopt 
the other opinion. It is not absolutely necessary, 
in admitting the existence of acute membranous in- 
flammation, that the membrane be thickened and of 
a redness evidently produced by capillary injection. 
In fact the serous membranes do not increase in thick- 
ness, in the most violent phlegmasia, and very often 
the redness, which colours them, resembles a kind of 
painting, absolutely the same as that observed in the 
cases we have mentioned. In acute pleurisy and pe- 
ritonitis, as we frequently have had occasion to ob- 
serve in examination of the body, we have met with 
large patches or long stripes of bright red, as if the 
membrane had been stained with blood, and without the 
least vestige of vascular injection. On the other hand, 
this absence of apparent capillary injection in inflam- 
mation of the internal membrane of the arterial sys- 
tem, will surprise us, perhaps much less, if we reflect 
that in the natural and healthy state, we cannot per- 
ceive any vessels in the tissue of this membrane, the 
nature of which, at present, has not been satisfactorily 



46 DISEASES OF THE AORTA. 

explained. Finally, some of the facts related in the 
two first cases, for example, the redness, certainly in- 
dicate an inflammatory nature; and analogy leads us 
to infer that such is also its nature in the following 
cases. Other reasons may be given which strengthen 
and confirm this analogy; in almost all these cases 
the redness in question coincides with more or less 
inflammation of the other organs, and in most of 
them foreign substances of an irritating nature, or 
different kinds of ingesta are introduced into the cir- 
culation, well calculated to produce inflammation of 
the internal vascular membrane, which receives the 
first impression of them. This is what most proba- 
bly takes place in phthisis, particularly in those cases 
where the suppuration of the tubercles is going on; 
in such cases there is more or less active absorption 
of purulent matter. 

An attentive examination of all these circumstances, 
the authority of many celebrated observers, has de- 
cided us to admit that the redness in question is a mark 
of inflammation; and we shall, therefore, no longer 
consider it as a phenomenon of imbibition, and trans- 
udation, or as an effect purely cadaveric. In every 
case we only propose our opinion as the most proba- 
ble, and are always ready to adopt another which 
shall be more conformable to observation and reason; 
until then we shall retain the opinion we have already 
formed. M. Laennec relates in his work that M. 
Recamier considers redness of the aorta as of an in- 
flammatory nature. This authority ought to have 
great weight with us. Mr. Hodgson says that red- 
ness is frequently observed surrounding a coagulum, 
and the same is observed in the arteries which have 



DISEASES OF THE AORTA. 47 

been a long time exposed to the air in the dissecting 
rooms. 

As to us, on the contrary, so far as regards the red- 
ness of the internal membrane of the heart, we have 
observed it to coincide more particularly with a state 
of remarkable fluidity of the blood; and it has ap- 
peared to us that the redness of the arteries dimi- 
nishes by long continued exposure to the air, espe- 
cially when it is moist. 



II. OBSERVATIONS ON CHRONIC AORTITIS. 
Case XXVII. 

Chronic Phlegmasia of the Internal Membrane of the Aorta, 'and 
slight Dilatation of the Arch* 

Pierre Guerle, aged fifty, shoe maker, of middle 
stature, and rather strong constitution, entered the 
hospital Cochin, on the 14th of June, complaining 
only that he had taken cold. 

On the 20th of the same month he presented no 
remarkable phenomena: he had spit a little blood; his 
pulse rather slow than frequent, was rather hard;, 
and a little vibrating ; percussion gave a flat sound at 
the left. 

On the 23d, he manifested great difficulty of respi- 
ration: expression of the face altered ; the patient, in 
other respects extremely tranquil, did not manifest 
any solicitude respecting his fate. The two follow- 
ing days he appeared a little better. 26th, orthop- 
nea and impending suffocation : face, which for many 
days had begun to assume a blue tint, presented this 
colour more decidedly: pulse constantly slow, regular, 



48 DISEASES OF THE AORTA. 

a little vibrating. Three following days respiration 
less embarrassed, although strength decreasing. 30th, 
patient expectorates vermilion coloured and frothy- 
blood : in the evening he fell into a kind of torpor, 
which continued during the night, and the next day, 
till after midnight, when death occurred after slight 
mucous rattle. 

Examination of the Body. The internal surface of 
the aorta throughout, and commencement of the ca- 
roted and primitive iliac arteries, were covered with 
white spots irregularly disseminated, the most of them 
situated beneath the internal membrane ; some were 
cartilaginous others osseous, or rather, formed of 
lamina of phosphate of lime, some of which were 
found in contact with the blood. 

The arteries indicated were unequal : the arch of 
the aorta was rather large, though not really dilated. 

The heart, of large size, adhered throughout to 
the pericardium, by a thin cellular tissue, not very 
firm and slightly infiltrated with albuminous matter; 
the cavities, especially the auricles, contained a large 
quantity of blood ; the walls of the left ventricle were 
very thick, and its capacity augmented; capacity of 
the right ventricle less than natural. 

The lungs, and particularly the right, adhered to 
the costal pleura by rather dense cellular tissue, and 
were engorged with blood at their posterior and in- 
ferior portion. In the present case, we could ex- 
plain the force and vibration of the pulse by the hy- 
pertrophy of the left ventricle, and deny that there was 
any relation with the phlogosis of the arterial texture; 
but it will not be so in the following case, where we 
^hall find the pulse, much stronger, coinciding with 
thinness of the left ventricle. 



DISEASES OF THE AORTA. 49 



Case XXVIII. 

Thinness and Dilatation of the Walls of the Left Ventricle; In- 
f animation and Ossification of the Aorta, fyc. 

Anne Berger, forty-seven years of age, botcher — 
has been afflicted for nearly two years with spasms, 
and many other analogous symptoms which she refers 
to a nervous affection produced by her turn of life. 
She was under the care of a great many physicians 
and surgeons, who all pronounced her disease to be an 
affection of the nervous system, and, consequently, pre- 
scribed anodynes and antispasmodics without success. 
From the time she entered the hospital Cochin, 13th 
of May, 1793, this patient suffered a great deal from 
difficulty of respiration. She was every moment 
afraid of being suffocated, and was obliged to remain, 
almost constantly, in her chair; she felt, she said, 
something rise up in the throat which almost choked 
her. She suffered great heat of the head; her feet 
were somewhat swollen. All the arteries sensible to the 
touch, seemed more dilated than in the ordinary state; 
their pulsations were thick and accelerated: those of 
the carotid arteries were very sensible to the sight; 
the movements of the arch of the aorta produced a 
kind of elevation towards the slope of the first piece 
of the sternum. The ulnar arteries beat with vio- 
lence; the patient said, also, that she felt pulsations 
in the interior of the body. Tormented with the 
fear of dying, she gave herself up to despair with the 
most incoherent expressions. 

The movements of the heart were precipitate, but 
presented, in other respects, nothing extraordinary. 

7 



50 DISEASES OF THE AORTA. 

All the symptoms increased more and more, and 
the patient died the 27th of the same month, after 
having suffered severely both in mind and body. 

Autopsy twenty-six hours after death. — The face 
was swollen; the whole body was marbled, and present- 
ed a great number of livid, somewhat extensive spots. 

The left cavity of the thorax contained a small 
quantity of reddish coloured liquid. The heart was 
more voluminous than in the natural state; the right 
auricle was distended by a considerable quantity of 
blood; the ventricle of the same side, and the pulmo- 
nary artery offered nothing remarkable. 

The left auricle was in a healthy state; but the cor- 
responding auricle was of twice the natural size, and 
its parietes were evidently thinned. The great sinus 
of the aorta was very apparent; the walls of this artery 
were hard, and thickened in many points. The in- 
ternal membrane was inflamed, from its origin at the 
left ventricle, to the common iliac arteries; the caro- 
tids were also, as well as the sigmoid valves. We re- 
marked, besides, in the whole of this extent, small 
hard whitish tubercles. 

The other arteries were in a state which appeared 
to us perfectly healthy. The abdominal organs pre- 
sented nothing peculiar, unless it was that the mesen- 
tery was sensibly distended by gas> which, in some 
places, formed small vesicles: the arteries of this mem- 
branous fold contained them also, and in rather large 
quantities. This case offers us, in their full force, 
the principal symptoms of arterial inflammation. 
These symptoms, in fact, consist essentially in aug- 
mented action of the arterial system, in pulsations 
quicks strong, vehement, and, as it were, vibrating, 



DISEASES OF THE AORTA. 51 

such as were observed in our patient. The pulsa- 
tions were so violent towards the hollow of the sternum, 
that we had suspected the existence of an aneurism 
of the arch of the aorta. This violence in the arte- 
rial contractions and dilatations was so much the more 
remarkable here, that it coincided with a thinning 
and dilatation of the walls of the left ventricle, two 
circumstances unfavourable to the force and quickness 
of the pulse. We are then obliged to admit a pecu- 
liar contractile power of the arteries, and an action in- 
dependent, to a certain extent, of that of the heart. 
The pulse, consequently, does not always indicate the 
state of the heart; but not only does the arterial sys- 
tem, in genera], exercise functions of its own, which 
may be increased in energy, without any participa- 
tion of the heart, but also the different branches of 
the arterial trunk are, in the same manner, indepen- 
dent of each other, and it is not unfrequent to find 
the pulsations of one artery much stronger and more 
forcible than those of another : the aorta, in particu- 
lar, offers us frequent examples of this phenomenon. 
Every one knows that individuals are not unfre- 
quently met with, affected with forcible beating at 
the epigastrium, the only symptom of their complaint, 
which, in fact, is nothing more than the aortal pulse, 
rendered more powerful, undoubtedly, in consequence 
of more or less acute irritation of the arterial tube. 
M. Laennec calls this affection spasm of the aorta, of 
which, as we before observed, all the other arteries 
are equally susceptible, although the affection in them 
is not so frequently mentioned as that of the aorta. 



52 DISEASES OF THE AORTA, 



Case XXIX. 



Chronic Inflammation of the Aorta, with Yellow Spots on its In- 
ternal Membrane; Pleuro- Pneumonia; Adhesion of the Peri- 
cardium to the Heart. 

A stone-cutter, named Albert, aged 24, fell, at the 
age of fifteen years, from a third story, on the right 
side of the chest. General and local bleeding removed 
the first complaints; but his health, which till then had 
been quite good, began to be deranged, and symptoms 
of catarrhal affections were not long in appearing, as 
well as vomiting and spitting of blood, at various in- 
tervals. After two years' military service, this af- 
fection having become more intense, he was dismissed. 
He could not inform us whether he, at that time, suf- 
fered palpitation. 

In the month of January, 1814, the lower limbs 
were affected with an oedema, which was entirely dis- 
sipated in the month of June. 

The 1st of January, 1815, the spitting of blood, 
which had become less frequent, again appeared, 
complicated with a stitch in the side. These symp- 
toms yielded to repeated blood-letting. At this 
period, the patient was sent to the Cochin hospital, 
by Dr. Devilliers; while we observed the following 
symptoms: the face was pale; the beatings of the 
heart were very strong and violent, heavy pulsations 
were felt at the superior part of the sternum, and in 
the left clavicular region, directly below these two 
bones: the head was forcibly shook ; the pulse was 
regular, but rather vibrating. The 3d of February, 
the beatings had become enormous, and raised the 
integuments with great force : passing the finger be- 



DISEASES OF THE AORTA. 53 

tvveen the two sterno-mastoids at their inferior part, 
we felt the sensation of a large tumour with a kind of 
trembling and rushing very distinct. Putting down 
the ear, we heard a considerable noise under the ster- 
num. The pulsations of the heart were so violent 
that we heard them distinctly, as we drew near the 
patient: they were isochronous with those of the 
tumour, which we thought we could perceive. The 
region of the heart did not give a very clear sound 
on percussion. 

Sleep was slight and short ; without, however, be- 
ing interrupted by sudden fright or starting. 

Such was the state of the patient to the 8th of 
February, when the students who attended the visit 
proposed to try the method of Valsalva. We con- 
sented, warning them, however, of the difficulty of 
putting it in practice, especially in an hospital. 
We prescribed two bleedings from the arm, at an in- 
terval of five days, and we restricted the patient to 
one portion of porridge a day, for his whole diet. Ne- 
vertheless, relax supervened eight days after, with ac- 
cessions of fever in the evening. On the 18th, symp- 
toms of adynamia appeared; the patient remained in a 
state of supination ; the lips and tongue were covered 
with a black and dry coat; the eyes remained immovea- 
ble and wide open; the respiration was slow, with con- 
siderable elevation of ,the thorax, the pulse regular, 
without frequency, had lost the vibrating character, 
which struck our attention at the commencement; the 
beatings of the heart, always strong, were felt in a 
great extent of the thorax; the patient could no longer 
speak or understand: infiltration was gradually ad- 
vancing. 9th, the respiration was slow and trembling, 



54 DISEASES OF THE AORTA. 

the mouth was covered with froth, which the patient 
could not spit out. 

The head was thrown backward, the eyes appeared 
vitreous and immoveable ; the pulse, was no longer to 
be felt, and yet the beatings of the heart preserved 
their force and extent, until death, which took place 
the same day, at nine o'clock in the evening. 

Autopsy. — The body was moderately, but gene- 
rally infiltrated. Percussion gave a flat sound on the 
right side, and obscure on the left. 

The costal and pulmonary pleura of the right side 
was covered, in the whole of its extent, with an al- 
buminous false membrane; the corresponding lung 
was hepatised in its inferior portion ; three quarters 
of its superior portion presented marks of inflamma- 
tory swelling much less distinct; the tissue being 
torn, a large quantity of serous and frothy fluid 
flowed out. The superior portion of the lung con- 
tained some softened tubercles, and even tubercular 
excavations : the left lung offered an adhesion of the 
costal pleura; but this adhesion was cellular, and ap- 
peared to have been a good while formed; while the 
false membrane of the right side appeared quite re- 
cent: we observed also, towards the summit of the left 
lung, suppurated tubercles. 

The pericardium throughout adhered to the heart, 
and was so intimately connected at its anterior sur- 
face, that we could only separate the two portions of 
that membrane by the most careful dissection; whilst 
posteriorly, we could easily destroy the adhesion 
with the finger, without the assistance of the scalpel. 

The heart, viewed in its situation, presented no- 
thing extraordinary; the right auricle was much di- 



DISEASES OF THE AORTA. 55 

latedj but without any sensible change of its texture • 
the walls, of the right ventricle were partially thinned 
without dilatation of its cavity. The left side oifered 
nothing special. The sigmoid valves of the aorta 
were larger than natural; their texture was thin with- 
out presenting any cognizable lesion; they were more 
dense than in the ordinary state, and seemed to pre- 
sent the rudiments of degenerated cartilage. The ori- 
fice of the aorta was evidently enlarged; but the aorta 
offered no dilatation. The external and fibrous coats 
were perfectly sound, but the internal offered here 
and there, as far as the curve of the arch, numerous 
yellow spots, which, below the arch, formed a kind of 
longitudinal band, along the posterior part of the 
artery. It was particularly at the origin of the caro- 
tids, that these spots were more apparent, and offered 
considerable thickness. We could easily pull off the 
whole of the internal membrane r it seemed neither 
more fragile nor easier to tear, in the places spotted^ 
than in those that were not. The other viscera were 
in the natural state. 

Let us return for a moment to the anatomical le- 
sions, which we have met with in our preceding 
patients. They consist principally of thickening of the 
arterial parietes, yellow, cartilaginous, osseous, and 
calcinous plates, with or without redness more or less* 
developed. In general, the plates mentioned are 
situated below the internal membrane, in such a man- 
ner, that we cannot resist admitting, that inflamma- 
tion determined a morbid secretion on the adherent 
surface or in the cellular tissue, which unites it to the 
middle coat, in the same manner as an inflammation of 
the arachnoid produces an analogous exudation bet weeni 



56 DISEASES OF THE AORTA. 

it and the pia-mater, or in its reticulated texture. 
This yellow exudation of the aorta, is transformed by 
a series of changes into fibrous, fibrocartilaginous, 
cartilaginous and calcareous lamina, in the same man- 
ner as the coagulable lymph of a pleuritic effusion is 
converted successively into cellular, fibrous, fibro- 
cartilaginous, and lastly osseous, deposition. These 
comparisons will no doubt convince those who enter- 
tain any doubt, of the inflammatory nature of these 
lesions of the aorta which we have been describing. 
We have not yet spoken of ulcerations of the aorta, a 
circumstance so favourable to the opinion which we 
have proposed. The cases XXXVII. and XXXVIII. 
from which we shall proceed to give an extract, will 
offer us some remarkable examples of this kind of le- 
sion, generally regarded as an indubitable sign of 
phlegmasia. 

A man, named Hivet, died of an aneurism of the 
aorta. — The walls of this artery were thickened; the 
cellular membrane was red and injected; the internal 
membrane was, if I may be allowed the expression, 
sprinkled with ulcerations, and, in many points, dis- 
coloured; we found underneath it a pultaceous gru- 
mous, atheromatous, yellow matter. This membrane 
was easily separated from the others, and was torn 
with the least force. The middle membrane itself 
was affected with several deep blackish-coloured ul- 
cers. The internal membrane, generally, was rough 
and uneven, and strewed with cartilaginous or calca- 
reous lamina; some of which, after having torn the 
membrane, were exposed to the current of the blood. 

Another man, named Pingon, aged 35, died of the 
same disease as the preceding. The walls of the 



DISEASES OF THE AORTA. 57 

aorta were thickened; the internal membrane was of 
a deep red, and strewed with a great many ulcerations, 
and also with an infinite number of calcareous or car- 
tilaginous lamina analogous to those above described. 
The ulcerations we have spoken of, are similar to 
the rudiments of aneurism, described by Scarpa, and 
an affection, more immediately fatal — we mean perfo- 
ration of the walls of the aorta, without the forma- 
tion of an aneurismal sac. We shall relate a recent 
example of this perforation observed by Dr. Ferris. 

Case XXX. 

Ossifications of the Aorta ; Ulcerated Perforations of the Walls 
of this Artery, at its Origin, with Effusion of Blood in the 
Cavity of the Pericardium, followed by almost sudden Death, 

A woman, named Lauret, had been a long time 
troubled with disappointments. For five months she 
complained of continual suffering, oppression, and 
looseness, when she was admitted to the Salpetriere. 
Residence in a hospital appeared to her dishonoura- 
ble, and this idea redoubled the painful regret of her 
former condition : nevertheless, she could get up and 
walk, and had a tolerable appetite. Every evening 
she went alone to her chamber, in the fourth story; 
not, however, without a good deal of difficulty. She 
went to bed at half past four, slept little, complained 
much, and was obliged to go to stool, frequently, 
during the night, — a great inconvenience to her 
neighbours. They demanded that she should be con- 
veyed to the Infirmary, but she refused. 

On the 20th of October, 1823, she received a visit 
from a nephew, whom she had not seen for seven 
years: she was very much afflicted that her relation 

8 



58 DISEASES OF THE AORTA. 

should see her in an hospital. On the morrow, her 
emotion was so much increased upon receiving a visit 
from a cousin, whom she had not seen for twenty-two 
years, that she fell into a fainting-fit, from which she 
with difficulty recovered, and was carried to bed. 
M. Belhomme was called, and found her lying on her 
side, with her face pale, and bathed with sweat: she 
respired with difficulty, and the heart scarcely beat. 
(Sprinkled with vinegar, friction of the limbs.) She 
was promptly relieved. M. Belhomme, after having 
prescribed an anodyne draught, had her conveyed to 
the Infirmary: as she was carried thither, at half 
past four, the following circumstances occurred in 
the stairway — oppression, suffocation, mucous rattle; 
followed by sudden death. After having placed her 
in bed, the house physician just mentioned was again 
called, who found her without pulse, face discoloured, 
and extremities cold : in short, in the state of a person 
who was about to yield the last breath. The exami- 
nation of the body was made by M. Ferris himself, 
physician of the hospital. The brain and cerebel- 
lum were not in the least altered. The lungs were 
healthy. The pericardium was uncommonly large, 
without any increased thickness of its walls ; its great- 
est development was at the lower and left part, where 
it touched the costal pleura, by pressing upward the 
left lung, the base of which was found removed 
twenty-six inches from the diaphragm. An incision 
made at its anterior part gave vent to four or five 
pints of serum a little turbid. A clot, several inches 
thick, weighing about eighteen ounces and a half, 
formed a complete envelope to the heart. This or- 
gan, pale, discoloured, with a little fat around it, is 



DISEASES OP THE AORTA. 59 

about the common size. The aorta, where it leaves 
the left ventricle, in the place where its walls are 
strengthened by the fold furnished by the pericardi- 
um, presents a round hole about an inch and three 
quarters in diameter, communicating with the cavity 
of the pericardium, and covered by the clot indicated 
above; all around, the arterial walls are thinned, and 
dotted with small red points, as far as the arch of the 
aorta; the neighbouring parts are infiltrated. Above 
the perforation the aorta is retracted, and in part os- 
sified: other ossifications are found at the origin of 
the arteria innominata, the left subclavian, and the 
carotid of the same side. The liver, very large, fills 
the left hypochondrium; its thin edge is covered by 
the transverse colon, its surface covered with slender, 
varicose veins, of a deeper red than common : to its 
concave surface adheres strongly the spleen, also 
very large, and presenting the same alterations. The 
stomach, large and pale externally, offered on its in- 
ternal surface, a rather deep rose colour, which fol- 
lows the intervals of the veins, and does not disap- 
pear by scraping. The intestines are distended by 
gas: their external and internal surfaces are pale; no 
other peculiarity was remarked.* 

Unquestionably, the strong moral emotion which 
agitated this woman, at the visit of her cousin, be- 
came the immediate cause of the rupture of the ul- 
cerated aorta; and the effusion of blood into the peri- 
cardium, in consequence of it, was the cause of the 
syncope w T hich occurred. Nevertheless, it is a very 
remarkable circumstance, that the patient did not 

* Observations published by M. Ferris in the third volume of the Archives 
Generate de Medecine, for December, 1823, p. 568. 



60 DISEASES OF THE AORTA, 

immediately sink under this terrible accident, but 
revived, and did not expire till an hour after, when 
she was carried to the infirmary; that is to say, when 
the movements and shocks, which were the inevitable 
effect of the conveyance, had detached the salutary 
clot, which had, without doubt, immediately covered 
the opening of the artery, and formed an obstacle, 
though a fragile one, to the flow of blood: a new proof 
of the necessity of perfect immobility in cases of hae- 
morrhage, where a similar cause has suspended the 
course of the blood; but, in this case, perhaps the 
most perfect repose would only have retarded for 
some hours an inevitable death. 

This very interesting case presents us with a mor- 
bid lesion of which the records of medicine contain 
but few examples. It is seldom we have an oppor- 
tunity of observing perforative ulcerations of the 
aorta opening into the pericardium ; nevertheless, we 
find some facts of this kind among observers, and 
especially in the works of Walter, Morgagni,* 
Scarpa,f &c. 

As an ulcer of the internal membrane of the aorta 
may be propagated to the middle and external mem- 
branes, and destroy them in their whole thickness, and 
thus transform them into a true perforation; so also 
an ulcer, which has commenced by the internal mem- 
brane of the heart, may destroy successively the mus- 
cular layers and serous membrane of that organ, to 
make its appearance in the cavity of the pericardium, 
and determine a perforation, followed by discharge of 
blood, quickly mortal. 

* De Sedibus et Causis Morbor., epist. 26. 
f Traitfc de Y Aneurisme. 



DISEASES OF THE AORTA. 61 

Our third case is an example of commencing ul- 
ceration, if we may so speak, of the internal mem- 
brane of the heart. We have not had an opportunity 
of seeing them deeper. Many ancient observers, 
such as Benivenius, du Laurens, Lazare Reviere, ap- 
pear to have observed ulcers of the internal surface 
of the heart, in cases of partial inflammation of that 
organ. Corvisart does not cite any example of his own; 
M. Laennec has recorded only one; the ulcer was 
situated on the internal surface of the left ventricle, 
an inch long and half an inch broad, and more than 
four lines deep in the centre; it occasioned a rupture 
of the ventricle, which appeared to have taken place 
two days before death. 

Rupture of the heart is a terrible accident: for- 
tunately, it is very rare, and is almost always the con- 
sequence of a perforating ulcer of the heart. Mo- 
rand has collected some examples in the Memoires de 
VAcademie des Sciences, for the year 1732; the 64th 
letter of the treatise De Sedibus et Causis Morborum, 
contains one; the work of Corvisart affords another, 
which was also seen by M. Ferris. 

Softening of the muscular substance of the heart is 
a circumstance favourable to the laceration of its walls. 
As to ruptures of the heart, without any previous 
change of substance, they are very uncommon; Haller, 
Morgagni and some others, nevertheless, cite a few 
cases, the immediate causes of which undoubtedly 
were external injury, uncommon exertion, and ex- 
cessive anger. 

We have seen a rupture of the right auricle, in a 
man who threw himself out of the window, during the 
pangs of most distressing dyspnoea. M. Grateloup, 



62 DISEASES OF THE AORTA. 

physician of Bordeaux, has recently sent an example 
to the office of the Archives Generales de Medecine. 
This physician was called, the 15th of November, 
1821, to a curate who had lost his reason. The pa- 
tient was already dead, when M. Grateloup arrived; 
the body was that of a man of plethoric and strong 
constitution. The whole exterior of the body was 
cold; there was a considerable effusion of red serum 
mixed with large clots of blood in the pericardium; 
the heart was large, and prodigiously fat; the right 
auricle was torn, about an inch in length. 

The subject of this observation, having supped as 
usual, was taken, at the moment of lying down, with 
considerable shivering of the hands and feet. He 
had hardly got into bed, when he was taken with nau- 
sea and vomiting; called his servant, and fell speech- 
less and insensible into his arms; became pale and 
cold, and immediately expired. Observation seems 
to have confirmed the opinion that a large quantity 
of fat about the heart, is a circumstance favourable to 
its rupture. It is probable, in the present case, that 
the strong reflux of blood into the auricle during the 
efforts of vomiting, was the immediate cause of the 
accident. 

M. Rullier presented to the Royal Academy of 
Medicine, at the sitting of the 6th of April, 1824, a 
heart, which offered on the internal surface of its ca- 
vities, many irregular tumours, which appeared to 
consist of fibrinous concretions which had been formed 
a long time before death; besides this, the parietes 
were perforated in two places. At the next sitting, 
M. Andral, jr. related a case of rupture of the heart, 
with perforation of the stomach. Death took place, 



DISEASES OF THE AORTA* 63 

suddenly, in consequence of strong moral emotions. 
The posterior wall of the left ventricle presented five 
oblong perforations situated in the direction of the 
longitudinal axis : the remains of the fleshy fibres, ir- 
regularly torn, floated around the perforations. The 
structure of the heart was not in the least softened. 

Corvisart was the first who collected cases of ano- 
ther species of rupture of the heart, which he de- 
signates by the name of partial rupture; by which 
is meant the rupture of the fleshy columns, and ten- 
dons of the valves. In the three cases recorded in 
his work, the rupture appears to have been owing to 
violent exertions. A similar fact has been observed by 
M. Laennec, and related in his Treatise on Mediate 
Auscultation : the accident consisted in a rent of the 
tendons of the valves, which seemed to have taken 
place in consequence of ulceration of the ligamentary 
cords. The symptoms which denoted this kind of 
rupture in the patients observed by Corvisart, were a 
sudden and almost complete suffocation, and, con- 
sequently, all the general phenomena of diseases of 
the heart. 

To the cases of Corvisart and M. Laennec, we 
shall adduce the following one of our own, in which 
a rupture of the fleshy pillar of the right ventricle 
was probably effected by a violent paroxysm of cough. 
This accident, in other respects, was not announced 
by any peculiar symptom, which would lead us to 
recognise or even suspect it. 



64 DISEASES OF THE AORTA 



Case XXXL 



Rupture of one of the Muscular Columns of the right Ventricle; 
in a Case of Phthysis. 

A young woman, named Sophia, aged 22, had ar- 
rived at the third stage of pulmonary consumption, 
when she entered the hospital Cochin, on the 30th of 
July, 1822. She had severe spells of coughing, and 
high fever, with a pulse so precipitous that we could 
with difficulty count the pulsations. She died in 
eighteen hours after she entered the hospital. Au- 
topsy, twenty-seven hours after death. The two lungs 
were entirely disorganized, and converted into a tu- 
bercular substance. The pericardium contained a 
portion of serum. The heart was rather firm, a little 
smaller than the fist of the subject, and rather bare of 
fat; the right ventricle filled with a kind of purulent, 
white, liquid matter, contained a small whitish clot: 
this kind of globular vegetation adhered to the ten- 
dons of one of the fleshy columns, which was broken, 
and was floating in the middle of the ventricular ca- 
vity. 

It seems to us that the perforations and ruptures 
of the heart and aorta present, in respect to the mode 
of their production, the greatest analogy with the 
ruptures and perforations, denominated spontaneous, 
of the stomach, the oesophagus, intestines, bladder, 
and uterus; and we might show the entire conformity 
of these pathological conditions, were it not that such 
a discussion, out of place here, would draw us too far 
from our principal object. 

We might also add a great number of other cases 
to those we have already given, relative to chronic 



DISEASES OF THE AORTA. 65 

phlegmasia of the internal membrane of the aorta; but 
we think we ought to confine ourselves to the pre- 
ceding, more especially as we shall see others when 
treating of the dilatations and aneurism of the same 
artery in many other parts of this work : because the 
diseases of this artery are so common that they are 
met with in almost all those which affect the heart. 

When cartilaginous , calcarious, or osseous indura- 
tions affect the valves of the aorta, heart, or pulmo- 
nary artery, a contraction of the corresponding ori- 
fices takes place, the effects of which are of so much 
importance, and the symptoms so well marked, that 
we thought it our duty to devote a particular chap- 
ter to this subject, as well as dilatation and aneurism 
of the aorta ; it is for this reason that we shall consi- 
der these important effects of phlegmasia of the in- 
ternal membrane of the heart and large vessels sepa- 
rately from the general history of this disease. 



ARTICLE II. 

General History of Inflammation of (he Aorta and Internal 
Membrane of the Heart 



1st, — Signs, Symptoms, and Characters of this disease. 

The signs of this inflammation are anatomical or 
physiological, that is to say, they are drawn from 
the anatomical alterations of the parts inflamed, and 
from the alteration or modification which these parts 
suffer in their proper functions. The anatomical 
signs can only be ascertained after death, while the 
physiological, as it is superfluous to say, can only ex- 
ist during life. 



66 DISEASES OF THE AORTA. 

SECTION I.— ANATOMICAL SIGNS. 

The signs or anatomical characters of the disease 
which occupies us consist of a redness of the parts 
affected, an effusion of pus and lymph, thickening, 
ulceration and gangrene of the textures; cartilagin- 
ous, calcarious or ossiform incrustations, formed either 
at the surface, or in the substance of the inflamed 
membrane; and lastly, a loss of cohesion and a species 
of fragility, which are observed in the same parts. 

A. The red colour of the internal membrane of the 
aorta and heart offers a great variety of tints. Some- 
times it is a scarlet red, sometimes poppy red, at 
other times violet, and then again it is of so deep a 
red, that it seems almost black; and lastly, it sometimes 
passes, by a kind of gradation, to a yellow tint. In 
general, the redness is much deeper in the right 
cavities, than in the left, and it is seldom that the 
scarlet tint is observed excepting in the aorta. The 
redness is also ordinarily more distinct on the valves 
than elsewhere, and appears to affect exclusively the 
internal membrane, because if this be detached we 
find the fibrous membrane of the same colour as m 
the natural state. 

We have never been able to observe any traces of 
vascular injection to account for this redness, yet M. 
Hodgson assures us that in the cases of acute inflam- 
mation which he had examined, the middle membrane 
always offered a degree of unnatural vascularity. 
We cannot compare this uniform redness to any thing 
better than a kind of stain. It is general or circum- 
scribed. We have seen it extend into the aorta in long 
bands, separated from each other by intervals, in 



DISEASES OF THE AORTA. 67 

which the membrane was entirely white. It may oc- 
cupy at the same time the aorta and its divisions, the 
heart, pulmonary artery and its ramifications, the 
vena cava and pulmonary vein; or it may have its seat 
in one, or several of these parts. We have submit- 
ted to maceration in water some of the vessels thus 
coloured, and the redness completely disappeared. 
This redness does not appear to be accompanied with 
thickening of the membrane. We have considered 
it as the result of an inflammation, whatever be its 
shade of colour. M. Laennec thinks the scarlet co- 
lour may indicate inflammation; but he compares the 
violet colour to that which is observed on the cheeks, 
on the mucous membranes of individuals affected 
with obstructed circulation, and even to a certain ex- 
tent to the livid state of the dead body. If there is any 
degree of redness, which may in fact be regarded as 
not inflammatory, it is unquestionably that of which 
we are speaking. New facts are necessary to enable 
us to pronounce in a positive manner on its true cha- 
racter. Constantly, as we have already said, the red- 
ness is deeper in the right cavities and pulmonary 
artery, than in the left cavities of the aorta. This dif- 
ference of tone, it appears to us, may be explained, at 
least in part, by that which exists in the colour and 
nature of the blood/ which flows in one or the other 
of its cavities: we know in effect that the blood, which 
passes through the first, the right blood, if we may so 
^peak, is browner and of a deeper colour than the 
left blood. Finally, this violet brown, and even black 
tint, is not a decisive reason why we should reject the 
idea of an inflammation; because many phlegmasia 
of the skin and the mucous membranes, and among 



68 DISEASES OF THE AORTA. 

others those which manifest a gangrenous tendency, 
are accompanied with a livid, violet, brown or 
blackish redness. 

B. Inflammation of the internal membrane of the 
heart, and aorta, as of every inflammation in general, 
sometimes gives origin to the effusion of an organized, 
concrete, or coagulable matter. Some of our cases, 
and especially the two first, are remarkable examples 
of it. If we do not find more frequently similar 
plastic effusions on the surface of the inflamed mem- 
brane, it is because the matter secreted is carried on 
in a state of solution into the current of the blood, 
with which it was found in contact; so that if the 
arterial walls were not thus separated from each other, 
by the column of blood, but put in immediate contact 
with each other, the concrete exudation of which 
we are speaking, would be followed by mutual adhe- 
sion. It is, in fact, what every body, at the present 
day, knows will happen if we apply a ligature to an 
artery. Therefore, if the adhesive inflammation has 
rarely, if ever, taken place in the aorta, it is neces- 
sary to search for the reason of it in the circumstances 
and conditions under which the arterial walls are 
found. Lastly, it is not rare to meet with arteries 
of a smaller size, obliterated in consequence of an ad- 
hesive inflammation of their internal membrane. It is 
indeed this disposition to adhesion, which prevents 
hemorrhage in the great disorganizations of many of 
the organs traversed by the large vessels; especially 
in the tubercular degenerations of the lungs. We 
have frequently met, around the walls of tubercular 
excavations, and in the bands or columns which 
traverse them, arterial branche v s obliterated in the 



DISEASES OF THE AORTA. 69 

mode we have described. We shall see, farther on, 
that the organized lymph, secreted by the internal 
membrane of the aorta and heart, appears to be the 
medium by which granulations and valvular vegeta- 
tions are produced. Farthermore, it is not the in- 
ternal surface of this membrane only which appears 
proper to secrete the materials, and if we may be al- 
lowed the expression, the rudiments of an accidental 
tissue or a new production. Its external surface ap- 
pears to be the seat of a similar exhalation; and it is 
thus that we may explain the formation of cartilagi- 
nous or osseous plates, so frequently met with under- 
neath this membrane; at least we should not prefer to 
admit, that these accidental productions originate in 
the midst of the matter secreted by the fibrinous 
tunic and cellular tissue which unites it to the in- 
ternal coat while in a state of inflammation. 

C. However it may be, the yellow points, cartila- 
ginous laminae, calcarious and limy incrustations of the 
aorta seem to us to be nothing more than a series of 
changes, through which passes, successively, the 
matter secreted by the effect of inflammation. The 
extent, form, and thickness of these accidental pro- 
ductions are infinitely varied. Sometimes they form 
only small yellow or whitish points, which render the 
internal surface of the artery unequal and rough; at 
other times we find this same surface, in a manner, 
plated with fibrous lamina, and fibro-cartilaginous 
layers much more extensive, and which are afterwards 
converted into osseous or calcarious incrustations. 
These often have the most perfect resemblance to 
egg-shells, and only differ from them, in some cases, 
by a greater or less degree of thickness. These cal- 



70 DISEASES OF THE AORTA. 

carious plates are most frequently situated underneath 
the internal membrane, but they are sometimes situ- 
ated in the texture of this membrane, or in that of 
the middle membrane; and it is not uncommon to 
meet with a considerable portion of an artery, the 
entire walls of which have been changed into phos- 
phate of lime, forming an inflexible and inorganic 
tube. We shall see, in some of the following cases, 
changes of this kind. It happens, also, that the cal- 
carious scales raise the internal membrane, tear it in 
some manner, and appear bare in the interior of the 
artery. Perhaps portions of these incrustations are 
finally detached, and form those kind of stones, which 
the ancient authors are said to have met with in the 
heart and in the aorta. We have generally remarked 
that a considerable injection of the cellular membrane, 
of the arteries, and of the aorta in particular, accom- 
pany the incrustations of which we are speaking. This 
degeneration occupies, sometimes, only a portion of 
the aorta. Frequently, however, it pervades its whole 
extent, and the facts which we have related, as well 
as others which we shall cite farther on, demonstrate 
that it is not unusual to meet with it in almost the 
whole extent of the arterial system. It is very common 
especially in the arteries of the base of the cranium and 
in their ramifications, and assuredly promotes the for- 
mation of many cerebral hemorrhages. We observe 
it more frequently in the arteries of the lower than 
those of the upper extremity. 

We knew a case, in which the aorta formed masses 
so thick around the whole of a portion of that artery, 
that it was almost entirely obliterated. Analogous 
degenerations, not unfrequently, contract the orifice 



DISEASES OF THE AORTA. 71 

of the arteries which originate immediately from the 
aorta. The name of ossifications, given to the calca- 
rious incrustations we are about to describe, is not 
altogether proper. The mode of their formation is 
not in the least like that of nominal ossification, or os- 
teogeny. We do not distinguish in them a fibrous 
structure, and they are produced by a kind of crystal- 
lization of phosphate of lime contained in the se- 
creted matter, in the midst of which it is developed. 
Some authors have compared the membrane which 
secretes this matter to the periosteum, and this com- 
parison is not, perhaps, so inexact as we might sup- 
pose; others have regarded these calcarious concre- 
tions not as morbid affections, but as a consequence 
of the progress of age, and they support their opinion 
on the circumstance that they are very frequently 
found in old men. But, notwithstanding this altera- 
tion is met with very often in the arteries of young 
subjects, and even in those of children, (although 
this is very rare,) it will always remain a problem, in 
what manner these calcarious plates arfe produced 
under the influence of the progress of age. Analogy, 
reason, and positive experiments on living animals, 
concur to prove that they are one of the terminations 
of inflammation. This truth has been clearly and inge- 
niously developed in a memoir which Dr. Rayer has 
published in the first volume of the Archives Gene- 
rales de Medecine. 

According to the chemical analysis, instituted by 
M. Brande, a hundred parts of these concretions 
contained 65,5 of phosphate of lime, and 34,5 of ani- 
mal matter. 

These concretions are sometimes developed very 



72 DISEASES OF THE AORTA. 

rapidly and in an acute manner; but in ordinary cases 
they proceed slowly, and are, in fact, the product of 
chronic inflammation. 

Instead of white or yellow spots, more or less pro- 
jecting on the interior of the aortal tube, and the in- 
crustations of which we have spoken, we sometimes 
meet with pustular and almost tubercular masses: and 
it is frequently by this kind of alteration that the ul- 
cerations commence, of which we shall speak here- 
after. 

D. The principal anatomical characters of the ac- 
cidental productions, which we have investigated, 
are almost constantly accompanied by a thickening 
and general hardening of all the arterial membranes. 
If we cut into the thickened, hypertrophied parietes, 
they grate under the instrument and oppose a consi- 
derable resistance to it, at the same time that the ar- 
terial texture is found deprived of its elasticity, and 
has become friable, fragile, and brittle: a new ana- 
tomical proof of the existence of an inflammation. 
Thickening of the walls, rarely takes place at the 
expense of the caliber of the aorta, but is almost al- 
ways united with a considerable degree of dilatation. 
It is, without doubt, in consequence of the loss of 
elasticity, which the aorta ha£ undergone, that in 
most of the cases we have spoken of, we have found 
it filled with more or less blood. We shall see, how- 
ever, that the deposition of the salts of lime, some- 
times form masses so considerable as to fill the arte- 
rial cavity and almost completely obstruct it. 

E. We frequently meet with the walls of the aorta 
ulcerated. These ulcerations vary much in depth 
and extent. They are sometimes very small and 



DISEASES OF THE AORTA. 73 

superficial, and implicate only the internal membrane; 
at other times they are considerably larger, with 
thick unequal edges, and so deep that the membrane 
itself in the part affected is entirely destroyed: in 
this case the bottom of the ulcer is formed by the 
cellular membrane only, as in the case of intestinal 
ulceration; and as the latter are sometimes converted 
into complete perforations, so the first may undergo 
a similar termination: case 30th, is an example of it. 
The perforation is completed in consequence of a 
violent impulse of the circulation, by rupture, and 
not by ulceration of the cellular or serous membrane; 
and, observe that the perforation of the aorta, with 
copious and sudden effusion of blood, happens pre- 
cisely at the place where this vessel is found covered 
by the reflected pericardium, or in some other point, 
where the surrounding cellular tissue, much contract- 
ed, cannot assist the formation of an aneurismal sac : 
hence, the effusion of blood into the pericardium, 
bronchia, &c. 

The ulcerations of the aorta sometimes have a dirty, 
sanious or even black appearance. We have found 
sometimes a little blood infiltrated in their circum- 
ference; at other times we have met with the internal 
membrane thickened, laid bare to a great extent, and, 
under its almost floating fragments, masses of a soft, 
pultaceous matter, analogous to that which forms the 
meliceris and atheroma: it is for this reason that 
Scarpa has given to this substance the name of an 
atheromatous alteration. We shall soon see the in- 
fluence of ulcers of the aorta in the formation of the 
false aneurisms of authors. We have already said, 

10 



74 DISEASES OF THE AORTA. 

that we have never observed deep and broad ulcera- 
tions in the internal cavities of the heart. We have 
only met with superficial and very narrow ulcers on 
the valvular and auricular membrane. We have re- 
ported some cases of rupture of the parietes of the 
hearty collected by other authors. We shall not 
speak of gangrene of the aorta, because we have 
never had occasion to observe it.* 

The different alterations we are to describe may 
exist separately, or combined in various ways with 
each other. We can scarcely conceive, on first in- 
quiry, how it is, that lesions so varied can be the ef- 
fect of one and the same disease. Nevertheless, on 
reflecting more attentively, we shall see that it is so. 
For this purpose, it will be necessary to consider in- 
flammation in a more extended point of view than 
is commonly done; it is necessary to observe this phe- 
nomenon in all its periods, and all its terminations; to 
study its modifications according to the tissue affected 
and its acute or chronic progress. The first signs of 
phlegmasia relative to anatomy, are redness, a cer- 
tain degree of tumefaction, and vascular injection. 
These are the only signs we can observe, if the dis- 
ease terminates by resolution. If suppuration super- 
venes, then very different phenomena appear, accord- 
ing as the purulent matter is thrown out or retained 
in the system. In the first case the inflammatory 
irritation abates after a certain time, the suppuration 
diminishes, or ceases entirely; and if an ulcer exist, 
its edges approximate, and a cicatrix soon forms on its 
surface. In the second case, on the contrary, a part 

• We shall- speak elsewhere of that of the heart.. 



DISEASES OF THE AORTA. 75 

of the pus* which has been secreted enters into the 
vascular system, and a part becomes organized, by- 
passing through a series of changes which it is of the 
highest importance to understand, which are not, pro- 
perly speaking, phlegmasia, but results and accidents, 
and consequently characteristic of inflammation. It 
is by this series of modifications that pleuritic pus, 
for example, becomes successively a kind of false 
membrane or amorphous mass, in which rudiments 
of vessels soon appear; an organized cellular tissue, 
a fibrous, dense, fibrocartilaginous, cartilaginous, or 
even osseous texture. Now, if this happens in pleu- 
ritic suppuration, why should it not occur in arterial 
suppuration ? And if the productions, of which we 
have given a rapid sketch of the appearances, are 
generally regarded as marks of chronic pleurisy, 
why should we not agree to consider the cartilagi- 
nous, fibrous and ossiform tissues of .the aorta which 
we have described above as traces of inflammation? 
To consider them in this point of view, is to conform 
to sound observation and the strict laws of analogy ? 
But, we delight to repeat it, these accidental tissues, 
or new productions do not constitute the essential 
properties of phlegmasia; they are only the circum- 
stances, terminations and accidents, if we may so speak, 
which belong to it: they resemble, in this respect, the 
indurations and cicatrices which we observe in cer- 
tain organs, which have been affected with phlogosis, 
as, for example, the brain. These cicatrices and in- 
durations of the cerebral substance are not an actual 
inflammation; but they indicate, that the point which 
they occupied had been formerly inflamed. 

* See Note C. in the Appendix. 



76 DISEASES OF THE AORTA. 

It should always be remembered, then, that the 
matter of suppuration, is the first condition of every 
formation of accidental tissue; that this matter, we 
say, varies in appearance and nature, according to the 
organs inflamed; wherefore it is not extraordinary, 
that the results of inflammation vary according to the 
tissue which it affects, and even according to some 
other circumstances. Thus, for example, the cellular 
tissue and the parenchymatous organs secrete pus, 
properly speaking; thus the serous membranes secrete 
a coagulable matter, ready to be transformed into 
cellular or serouslamina; thus the periosteum furnishes 
another matter which concretes, hardens and ossifies; 
thus the arterial tissue, composed essentially of fibrous 
membrane, exhales a liquid which becomes hard, 
condensed, and is converted into cartilaginous lamina 
or calcareous scales. 

SECTION II.— PHYSIOLOGICAL SIGNS. 

It is not so ^asy to exhibit the physiological, as the 
anatomical signs of aortitis. Among the causes which 
perplex our diagnosis, we must consider the situation 
of the organ diseased, which conceals it, in a great 
measure, from the observation of the senses, and the 
various complications with which aortitis is accom- 
panied. If we analyze strictly the cases already 
given, and if we consider more attentively the most 
simple, as the 27th, 28th, and 29th, we shall see that 
pulsations much stronger than in the natural state, are 
the only manifest symptoms which have denoted the 
disease, a pain, and sensation of heat in the region of 
the aorta, anxiety, and fainting, are symptoms less 
constant, but which it is nevertheless important to 



DISEASES OF THE AORTA. 77 

notice. We have presented two cases in which the 
pulsations of the aorta were so violent that we sus- 
pected an aneurism of this artery; the autopsical ex- 
amination proved that there did not exist an aneurism, 
but only phlegmasia of the aorta. The position of the 
thoracic aorta is such that we cannot appreciate the 
intensity of its pulse, excepting towards the depres- 
sion at the top of the sternum: on the contrary, by 
applying the hand, or, what is better, the stethoscope, 
on the abdomen, we feel the pulsations of the ventral 
aorta, and it is by this kind of exploration, that we 
may come to a knowledge of the disease which oc- 
cupies us. We shall examine, in the article on true 
aneurism of the aorta, how auscultation may lead us 
to distinguish simple irritation of the aorta from its 
aneurismal dilatation. 

The violent pulsation of the aorta, which we re- 
gard as the principal sign of aortitis, is often accom- 
panied by a similar pulsation in all the large branches 
of the arterial system. The reason of this phenome- 
non is very simple: it is because the phlegmasia of the 
aorta coincides so frequently with that of the other 
arteries. We have already said, and we repeat it 
here, that the aorta alone may present an augmented 
energy of pulsation; and what we may observe in the 
aorta, may be observed, and is in fact observed in 
every other arterial trunk of considerable size, be- 
cause inflammation of the arteries may be general or 
local. 

If it be very true that aortitis is characterized by pul- 
sations quicker and more vehement than in a state of 
health, this symptom, far from surprising, ought, on 
the contrary, to make us perceive that physiology 



78 DISEASES OF THE AORTA. 

and observation would have sufficed to make us fore- 
see it. Experiments on living animals have proved 
that the arteries are endowed with vital contractility, 
with a peculiar irritability, which different agents 
excite in a very sensible manner : now, inflammation 
of an artery is nothing more than an exaggeration of 
these properties, and from this exaltation ought, ne- 
cessarily, to result pulsations more vigorous than in 
the natural state. On the other hand, observation 
of the phenomena of a local phlegmasia, a panaris, for 
example, teaches us that in this case, arteries, in 
which no pulsation could previously be felt, have of- 
fered them very distinctly, a circumstance which 
can be explained, only by the irritation, with which 
they have been affected: now, the phenomena which 
occur in these smaller arteries, we should expect to 
find in the large arteries on a corresponding scale. 

It is, farthermore, evident that the symptoms above 
enumerated, can only be developed while the arte- 
rial texture has not yet undergone any deep disor- 
ganization and the phlegmasia is more or less acute 
in its course, but when the inflammation has continued 
a long time and has converted the parietes of the ar- 
teries into a cartilaginous or osseous substance, it 
should be classed among the latent phlegmasia, the 
diagnosis of which is invested with the greatest diffi- 
culties. Then it is no longer an extraordinary acti- 
vity of the artery diseased which is observed : the 
walls, thus altered, become more or less unfit to carry 
on their functions, the circulation of the aorta lan- 
guishes; and thence follows, according to many au- 
thors, one of the most frequent causes of dilatation 
and hypertrophy of the heart. 



DISEASES OF THE AORTA. 79 

We have, as yet, considered aortitis only in its 
most simple state: when it is complicated with the 
phlegmasia of the principal viscera, with the fevers 
called idiopathic, acute, or chronic, its combined 
symptoms, confounded with those of the diseases su- 
peradded, become very difficult to distinguish; ne- 
vertheless, we may observe that a more or less con- 
siderable irritation of the aorta exists almost always 
where very high fever is present. But then it is not 
only the aorta, it is the whole vascular system, and 
the heart, itself, which participated in the irritation: 
it is also in cases of the kind we have stated, a well 
marked redness of the membrane of the heart, aorta 
and pulmonary, and large veins may be observed. 

As to the inflammation of the membrane of the 
heart alone, it is uncommonly rare; analogy indicates 
that it should be characterized by an augmented force 
and frequency of the pulsations of the heart and pulse, 
when it is not so violent as to diminish, suspend, or 
arrest entirely the action of this organ. Observation 
confirms what analogy would lead us to foresee. In 
fevers, properly speaking, which seem to us to be con- 
stantly accompanied with an irritation of the heart, 
the frequency and force of the pulse are the two prin- 
cipal phenomena to be observed; so that if the fever 
assumes a grave character, and determines an intense 
inflammation of the heart, so that the muscular sub- 
stance of this organ be affected, the pulse loses its 
force and regularity by increasing in frequency; and 
sudden death often terminates this formidable com- 
plication. 

But we shall return to this subject when speaking 
of inflammation of the substance of the heart. 



80 DISEASES OF THE AORTA. 

Violent pulsations of the aorta do not always an- 
nounce a phlegmasia of its membranes, nor an aneu- 
rismal dilatation; circumstances purely physical may 
produce such pulsations. If we should find, for ex- 
ample, upon the aorta any body, which could trans- 
mit its pulsations with greater force than the parts 
which naturally surround it, we should observe the 
same phenomena as if the pulsations of this vessel had 
become more energetic in consequence of a phlegma- 
sia. This truth, which auscultation has incontestably 
proved, was pointed out by Mr. Th. Young in 1815;* 
but he has drawn from it, at least in our opinion, 
conclusions, some of which are not very accurate. 
This author pretends that the anormal pulsations, 
which we might easily mistake for an aneurism, or 
for an effect of the independent action of an artery, 
is explained by the existence of a liquid effused into 
a cavity, which effusion propagates and communicates 
most easily the pulsatory movements. It is on this 
account that, in ascites, on compressing the umbili- 
cus moderately, we feel the pulsations of the aorta. 
It is for the same reason that, in cases of hydrotho- 
rax, the pulsations of the heart are felt in a great ex- 
tent of the chest. These remarkable assertions of 
Mr. Young are very just: we were not acquainted 
with them, till after long continued practice of aus- 
cultation we were led to make the same observations. 
It is certain that the accumulation of a fluid in the 
pleura or the peritoneum, produces the effect indi- 
cated by Mr. Young, that is to say, that it conveys 
with greater force the pulsations of the heart, and 

* Medical Transactions of the College of Phys. of London, vol. v. 1815, 
No. 15. 



DISEASES OF THE AORTA. 81 

aorta, and especially the noise which accompanies 
these pulsations. Many phenomena, furnished by 
auscultation, are explained admirably, by means of 
this remark; such as resonance of the voice and pul- 
sations of the heart, in the points of the chest where 
there exists an accumulation of serum, such are the 
beatings which we hear in auscultating the abdomen 
of women in a state of pregnancy, &c. 

In other cases it is not a liquid, but an abdominal 
tumour, more or less voluminous, which transmits 
the pulsations of the aorta with such an intensity, as 
to imitate those of aneurism: hence the ingenious ex- 
pression of false aneurism, by which M. Laennec has 
distinguished this disease, or rather this phenome- 
non. There are few physicians, who have not had 
occasion to observe these anomalous pulsations of the 
aorta, which some have called spontaneous pulsations, 
others, with Morgagni, spasms of the aorta. M. Lan- 
nec admits, in explanation of them, that the tumour 
which we feel in front of the ventral aorta is formed 
by gas confined in some manner in one of the parti- 
tions of the transverse colon. * He is of opinion, 
also, that an accumulation of hardened fcecal matter 
produces the same effect. Combe reports the case 
of a patient, who had a violent and importunate pul- 
sation in the umbilical region, and who after very 
acute pain in the abdomen, passed some hardened 
fcecal matter : he died, and at the opening of his body 
there was found an extraordinary contraction of a con- 
siderable portion of the colon and ilium «? and the aorta 
perfectly healthy. 

* Auscult. Med. lomr ii. p, 444,- 
11 



82 DISEASES OF THE AORTA, 

The pulsations respecting which we have said a 
few words, are much less frequent than those which 
depend upon a more or less considerable irritation 
of the aorta, \ These have been confounded with the 
others by a great many authors: nevertheless it is very 
important to be able to distinguish them; for their 
nature being entirely different, the treatment must 
be different also. 

When the ulcerations of the aorta, instead of giving 
origin to the formation of an aneurismal sac, terminate 
by a true perforation, a mortal hemorrhage is the 
result, of which case XXX has furnished us with an 
example : it is the same also with the perforations of 
the heart. 

2d. The predisposing as well as the exciting causes 
of inflammation of the internal membrane of the aorta, 
and the vascular system in general, are rather nume- 
rous. From our own observations, and those of other 
authors, it is incontestable, that external injuries, 
such as falls, contusions, &c, violent exercise, and 
all the causes capable of quickly exciting the course 
of the blood, ought to be - classed in the number of 
agents proper to produce an inflammation of the aorta. 
We might say the same of ingesta, too stimulating, or 
which possess properties more or less deleterious: this 
is the reason why we often find this disease in indi- 
viduals, who indulge in spirituous liquors,* who in- 
dulge too freely in high living; in those who are affect- 
ed with severe fevers, or any other disease, in which 

* M. Toussaint Leroy has communicated to us the case of a man, who 
died after having drank a bottle of brandy, in whom was found an inflamma- 
tory redness of the whole vascular system. 



DISEASES .OF THE AORTA. 83 

the altered blood possesses properties more or less 
irritating. The cases, which we have reported 
prove the correctness of our assertions. Perhaps, 
also, the various poisons, the gouty diathesis, have 
an unfavourable influence in producing this disease. 

There is one cause in particular which seems to 
exercise great influence in the production of aortitis 
as well as arteritis in general : we refer to hypertro- 
phy of the left ventricle. If this cause be the true 
one, as Morgagni thinks, we can only explain it, by 
admitting that the arteries are irritated by the vio- 
lence with which the column of blood propelled by 
the heart rushes against their walls. Morgagni re- 
ports a case from Boerhaave which seems to favour 
this opinion: this case is drawn from comparative 
pathological anatomy; it consists in this, that accord- 
ing to Boerhaave we do not observe ossifications at the 
origin of the aorta in stags v^ich are brought up 
tranquilly in the parks of the great, whilst we meet 
with them in stags which have been a long time and 
very frequently run in a chase. However it may 
be, Morgagni makes use of the following curious re- 
mark to support the reasons which make him believe 
that the force with which the heart propels the blood 
into the aorta, may suffice to produce the various 
changes which we have previously described. 

3d. The Prognosis of pure and simple aortitis is 
not unfavourable, except from the consecutive ac- 
cidents which may supervene, such as perforation of 
the walls of the aorta, or aneurism. When it is com- 
plicated with violent phlegmasia of the principal vis- 
cera, with fevers called essential or idiopathic, it is 
cm the symptoms of these last diseases that the prog- 



$4 DISEASES OF THE AORTA 

nosis should be founded; hence, the reason why we 
think we ought to confine ourselves to these rapid 
remarks on this point of the history of aortitis, and 
we now proceed to the treatment. 

4th. The Treatment of aortitis reposes on the same 
general principles as that of the other phlegmasia 
Free, general and local bleeding, diet and diluent 
cooling and dimulcent drinks are the principal means 
to be adopted; if there is, indeed, an inflammation in 
which the utility of blood-letting is incontestable, and 
if I may be allowed the expression, palpable, it is in- 
dubitably that which is the object of our present re- 
searches. Absolute repose is also indispensably neces- 
sary, since movement, exercise, and especially ex- 
ertions, are evident causes of irritation of the aorta. 

The employment of means to calm the activity of 
the sanguiferous system, ought not to be neglected. 
Of all these, withoutMloubt the most commendable is 
the digitalis purpura, under some one or the other 
of its forms; taking care always to increase the dose 
gradually. 

Finally, if the aortitis should appear to be owing 
to any specific cause, it is evident it would be neces- 
sary to recur to the substances, which experience 
has confirmed to be effectual in similar cases; we 
shall only observe that, on the supposition it might 
be attributed to a venereal taint, the administration of 
mercury would regain great prudence, if it be true, 
as some physicians assert, that this medicine itself, 
sometimes occasions phlegmasia of the vascular sys- 
tem. 

It is necessary to add, that the complications with 
which aortitis may be associated are a fruitful source 



DISEASES OF THE AOKTA. 85 

of new indications, which the practitioner ought 
never to lose sight of. Aortitis being rarely idio- 
pathic, but more frequently sympathetic, it is neces- 
sary to adapt the treatment to the principal disease. 
We shall finish this chapter with two cases of 
phlegmasia of the aorta which were cured. 



Case XXXIL 

Aortitis cured. — Margaret Pachot, married wo- 
man, aged 28, vinedresser, of middling stature and 
sanguine lymphatic temperament, had ceased to be 
regular for eight months previous to her making any 
complaint, w T hen she entered the hospital Cochin, the 
29th July, 1822. Was taken sick with catarrhal 
disorder, for which she took four or five emetics. 
She has been languid ever since, and presented, on 
-arrival the following condition : pain in the middle 
and right side of the chest; oppression, cough with 
moderate expectoration; entire inability of lying on 
the left side; lancinating pains in the epigastric region 
and the abdomen; slight oedema about the malleoli in 
the evening, complexion yellow; tongue white, rather 
dry; thirst, nausea, constipation, pulse quick, vi- 
brating, hard and frequent; febrile paroxysm at night, 
with sweats, especially at the epigastrium; drowsiness, 
startings from sleep, feeling of weakness. We hear 
a kind of purring rattle in a large proportion of the 
chest: the beatings of the right ventricle are much 
more clear and sonorous than those of the left ven- 
tricle, which are dull and concentrated. If we apply 
the cylinder to the umbilical region, we hear the 



86 DISEASES OF THE AORTA." 

pulsations of the aorta, which are simple, rather so- 
norous, of a moderate impulsion, giving the sensa- 
tion of the ordinary caliber of the artery. It is suf- 
ficient to apply the hand to the abdomen to feel its 
pulsations, which the patient had not perceived till 
within six weeks : they increased in intensity by par- 
oxysms; when the patient is threatened with fainting, 
and the pulsations, she says, strike her to the heart : 
while she was sitting up, she suffered from vertigo, and 
cephalalgia, like the blows of a hammer upon the 
head. (Expectorant electuary, laxative lavement, 
quarter diet.) 

The 1st of August, twenty leeches were applied 
to the side. The following days, the pulsations were 
no longer sensible to the hand; nevertheless the 
patient complained from time to time of cephalalgia, 
and acute pain, with a kind of convulsive beating of 
the heart: her face was pale, and less discoloured. 
Twenty leeches were applied to the anus, on the 16th 
of August. On the 17th and 18th, she was much 
relieved and disposed to leave the hospital; at inter- 
vals she was troubled by chills and cold sweats. On 
the 21st, she no longer felt the pulsations in the ab- 
domen; which, in fact, had completely disappeared; 
she no longer complained of faintness, and suffered 
only slight inconvenience of the head; she requested 
and obtained her discharge. 

An old soldier, far advanced in years, of an irasci- 
ble, violent character, entered the Hotel Dieu during 
the year 1823, for intense beating in the abdomen. 
On applying the cylinder to the middle of this re- 
gion, it was raised, and as it were thrown up by the 
simple pulsations, which were of such violence, that 



DISEASES OF THE AORTA. 87 

they were heard in the whole extent of the abdomi- 
nal aorta, the caliber of which did not seem to be aug- 
mented; no bellows sound, either in this, or the pre- 
ceding case, was heard; the pulse was hard and vi- 
brating. M. Recamier, whose ward the patient oc- 
cupied, had forty leeches applied in the direction of 
the aorta. After some days the pulsations ceased, 
and the patient left the hospital perfectly cured. 



88 DISEASES OF THE AORTA. 



CHAPTER II. 



ON DILATATION AND ANEURISM OF THE 
AORTA. 



PRELIMINARY CONSIDERATIONS. 

The first notions entertained respecting aneurism 
of the aorta, can scarcely be traced back so far as the 
period when the great anatomist Vesalius flourished. 
In the course of the sixteenth century, the doctrine 
of the dilatations of the aorta made but slow progress, 
as the illustrious Morgagni has before observed. In 
the following age, Riolan advanced that aneurism of 
the aorta, meaning thickness of its coats, rarely oc- 
curred; and Eisner regarded the case of an aneurism 
of the great artery, observed by William Riva, as a 
wonderful circumstance; but towards the end of the 
seventeenth century, and during the course of the 
eighteenth, pathological anatomy having been culti- 
vated with redoubled zeal, so many new facts were 
added to those with which science .had already been 
enriched, that dilatation of the aorta no longer ap- 
peared wonderful, or even rare. Notwithstanding 
the labours of Lanusi, Valsalva, Morgagni and many 
other commendable physicians, much has always re- 
mained to be done for the history of aneurism of the 



DISEASES OF THE AOHTA. 89 

aorta. The diagnosis of this disease has always been 
enveloped in profound obscurity, and its relation 
with chronic phlegmasia of the parietes of the aorta, 
had not been sufficiently distinguished. Scarpa, 
Corvisart, Laennec, Kreisig, Hodgson, have, without 
doubt, thrown a precious light on this interesting 
subject; and perhaps our own researches may not have 
been entirely destitute of value. We shall endea- 
vour to develop more just ideas on the mode of for- 
mation of dilatations and aneurism of the aorta, and 
dissipate, as much as possible, the clouds which ob- 
scure the diagnosis of this disease. We shall begin 
by stating facts, and then proceed to give a general 
history of aneurism of the aorta. 



ARTICLE I. 

Observations Relative to Dilatation and Aneurism of the Aorta, 
whether true or false. 

Case XXXIII. 

Dilatation of the Aorta, and Ossified Plates of the Internal 
Membrane. (Chronic Aortitis. J 

Catherine Pongeau, domestic, aged 33, admitted 
for the first time to the hospital Cochin, in 1812. 
Suffered, for eight days, a violent pain in the left 
side of the chest, which augmented on inspiration, 
and was accompanied by frequent cough, with diffi- 
cult expectoration of mucous sputa mixed with streaks 
of blood. These symptoms were promptly relieved 
by bleeding from the arm, expectorant drinks and 

12 



90 DISEASES OF THE AORTA. 

juleps. This woman was afflicted for eighteen months 
with very distinct pulsations in the lateral inferior 
parts of the neck, which she attributed to an effort in 
raising a weight. These pulsations, at first rather 
weak, had become progressively stronger, and were, 
at last, accompanied by pulsatile pains of the head, 
difficult, precipitous, and even panting respiration, 
especially when she went up stairs. These pulsations 
commenced at the depressions found behind the cla- 
vicles, and traversed very nearly the course of the 
carotids: they were sensible to observation, frequent, 
more extensive on the right side, isochronous with 
the pulse and beatings of the heart, and regular like 
them ; they produced a general shock, and the sleep 
of the patient was frequently disturbed by sudden 
starts, which might be reasonably attributed to this 
cause. The slightest moral impression sensibly in- 
creased the pulsations^ they became, obviously, more 
violent as soon as we approached the bedside of the 
patient; and, as if she had a mournful presentiment of 
the fate which awaited her, shed tears when we 
asked her any questions, or endeavoured to calm her 
distress. In other respects, after the example of me- 
lancholy people, she was often sad and gay, alter- 
nately. 

She complained of habitual stunning, her face was 
red, and occasionally animated; she could retain with 
ease the horizontal posture, but could not lay any 
length of time on the left side; she sometimes had 
palpitation, but the beatings of the heart were usually 
deep, scarcely sensible, frequent and regular^ the 



DISEASES OP THE AORTA. 91 

pulse was, in general, frequent, feeble and hardly 
Sensible; respiration, rather easy in a state of repose, 
was painful on the least exercise. 

This patient, after having obtained temporary re- 
lief, from the use of antispasmodic draughts, bleeding 
from the arm, and the application of leeches to the 
anus, left the hospital the 12th of May of the same 
year. 

Obliged to resume her laborious occupation, she 
soon experienced the same symptoms, and at the end 
of six months, again entered the hospital. After 
having remained stationary till the month of January, 
these symptoms appeared, at that time, augmented in 
intensity; the beatings of the heart became very strong, 
the pulse tense and vibrating; the pulsations, already 
described, were always isochronous with the beatings 
of the heart; the carotid arteries, very perceptible, 
seemed to undergo a very remarkable dilatation, 
about an inch in extent, and immediately above the 
clavicle: on applying the fingers to this place, a 
jarring tremor and peculiar rushing sound were per- 
ceived. 

On the 19th, the pulse doubled its force and fre- 
quency, the whole body was covered with sweat, and 
the face had a fed and lively expression. 

During the whole day of the 20th, the patient was 
remarkably gay; in the evening, however, she felt 
an inexpressible anxiety, and died suddenly the fol- 
lowing night. 

Inspection of the Body. — The right pleura pre- 
sented adhesions; the lungs were healthy; the peri- 
cardium contained but a small quantity of serum* 



92 DISEASES OF THE AORTA. 

The anterior surface of the heart, was covered 
with layers of fat; the volume of this organ was about 
one third larger than in the natural state; the thickness 
of the walls of the left ventricle had doubled, and its 
cavity was increased in the same proportion; the 
right ventricle presented nothing peculiar. The 
orifice of the aorta was enlarged; the free edges of 
the aortal valves were thickened and rounded; the 
tubercle which occupies the middle part was ef- 
faced. 

The caliber of the aorta, from its origin, as far as 
the left subclavian, was at least four times the na- 
tural size; from the subclavian, as far as its passage 
through the diaphragm, it was, in like manner, di- 
lated: the interior of this artery was almost entirely 
covered by osseous plates of various sizes, some of 
which were bare, although the greater part were 
covered by the internal membrane. Immediately in 
front of the origin of the arteria innominata, the aorta 
was perforated by an aperture which would admit 
the tip of the fore-finger, and which communicated 
with a small cellular cyst, rather thick, and about the 
size of a pigeon's egg.* 

After its passage through the diaphragm, the aorta 
resumed its usual size, and its internal membrane was 
free from the points of ossification of which we have 
spoken. 

The arteria innominata presented, at its origin, a 
remarkable dilatation, about an inch in length, with- 

* Could the disposition of Ihese parts be attributed to the remains of an 
old aneurism spontaneously curee. ? (See, on this subject, the article con- 
cerning the treatment and spontaneous cure of aneurism of the aorta.) 



DISEASES OF THE AORTA. 93 

out having suffered any rupture of its coats : the ca- 
rotid arteries offered nothing in any respect extraor- 
dinary. 

The thyroid gland was large and hard. 

The mucous membrane of the stomach was of a red- 
dish-brown colour. 

The right lobe of the liver was contracted, shri- 
velled within, and reduced to much less than the na- 
tural size. 

The brain and its membranes offered nothing re- 
markable; the ventricles contained only some drops 
of serum. 

Case XXXIV. 

Aneurism of the Aorta ; and Chronic Inflammation of its Inter- 
ternal Membrane. \ 

Joseph Bertrand, horse-jockey, aged 68, admitted 
to the hospital Cochin the 2d of February, 1815, pre- 
sented rather equivocal symptoms of organic disease 
of the heart. He had suffered for a long time from 
short and accelerated respiration; lost his breath 
shortly after walking or going up stairs; could not 
lie with the head low, without feeling suffocated; had 
frequent cough, accompanied with free and puriform 
expectoration. The pulsations of the heart offered 
nothing very remarkable, only they appeared a little 
stronger than natural for two or three days after the 
patient first entered the hospital, but they soon be- 
came weaker, so much so, as to be scarcely sensible : 
the pulse was weak, but sufficiently regular; the legs 
were slightly (Edematous. 

The dyspnoea augmented more and more, and the 
patient died twelve days after his entry. 



94 DISEASES OF THE AORTA. 

Inspection of the Body. — The aorta, from its ori- 
gin to its curvature, offered an enormous dilatation, 
which, evidently, affected all the coats. 

This vessel was uniformly dilated in its whole cir- 
cumference: No peculiar cyst could be observed; 
its internal membrane was throughout yellow, thick, 
and friable, but did not present a rupture.— The de- 
scending aorta was also dilated, but in a much less 
degree: this dilatation gradually diminished, and ter- 
minated at the coeliac artery. In its whole course, 
the three coats were uniformly dilated; the internal 
presented yellow plates and had a tubercular appear- 
ance. We farther observed, in some points, and es- 
pecially towards the coeliac trunk, erosions, and spots 
similar to ecchymosis. 

The pericardium adhered in many points to the 
heart, the cavities, walls and orifices of which were 
in the normal state. 

The lungs adhered to the costal pleura; and the 
parenchyma of the superior portion was indurated. 

Case XXXV. 

Dilatation of the Thoracic Aorta, with Latent Phlegmasia of its 
Internal Membrane. 

A man named Julien, aged 56, was admitted to the 
hospital Cochin on the 9th of March, 1815. He en- 
joyed in his youth tolerably good health; but about 
two years before his entry, fell from a coach, on the 
pavement, and since that period respiration has been 
more and more difficult, so that he was obliged to stop 
when walking quick on going up stairs. For nine 
months past he has been troubled with continual cough, 
and for the last eight days the limbs have been infil- 



DISEASES OF THE AORTA. 95 

tratedi he could no longer enjoy rest, remained sit- 
ting in his bed, and whenever he attempted to lay in 
the horizontal posture, was immediately in dread of 
suffocation. The beatings of the heart were remarka- 
ble for their force ; and a species of shock could be 
very distinctly felt across the walls of the thorax. 
The chesty large and well formed, gave a flat sound 
at the left : the pulse regular, strong, and vibrating 
in the right arm, was very weak in the left. 

Appetite was retained, thirst was very great, the 
bowels were free, and the urine was red and suffi- 
ciently copious. 

He was bled, with momentary relief. 

But on the 27th of May, the swelling had increased 
and extended to the upper extremities; the cough 
was more frequent, and the dyspnoea more intense; 
the beatings of the heart seemed to have lost their 
force, but could be felt in a greater extent* 

On the 31st the patient could not remain long in 
any position, he laid over the edge of his bed, com- 
plaining of something in the throat which choked 
him; respiration was, in fact, much accelerated, and 
suffocation threatened. The pulsations of the radial 
artery continued to be much stronger in the right 
than the left arm, where they were scarcely to be felt. 

Nevertheless, during the three following months, 
the patient remained in nearly the same state, with 
the exception of alternate increase and diminution of 
dyspnoea and oedema. 

Finally, on the 5th of July, all the symptoms aug- 
mented, and the patient died on the 7th. 

Inspection of the Body. — The pericardium was 
closely united to the heart: the adhesion was, howe- 



96 DISEASES OF THE AORTA. 

ver, a little looser on the anterior surface than else- 
where, where we could not separate the adventitious 
membranes which had produced it. The walls of 
the left ventricle were more than double the natural 
thickness; its cavity was also enlarged. The valves 
and orifices were healthy. 

The right side of the heart presented nothing ex- 
traordinary. 

The aorta was dilated from its origin to the place 
where it gives off the coeliac artery; and the dilata- 
tion was equally participated by all three of the 
coats. Opened in its whole length, it presented a 
great number of wrinkles, for the most part longitu- 
dinal; and many yellow spots, of some lines in extent, 
on which the internal membrane was very easily torn, 
while it appeared healthy in the intermediate spaces. 
The middle coat was thicker than in the natural state. 
The aortal valves were rather hard in some parts, 
but in other respects free from disease; the opening 
which they circumscribed was large. The left sub- 
clavian was contracted at its origin, and its caliber 
was inferior to that of the right subclavian. 

The left costal pleura adhered to the correspond- 
ing pulmonary pleura: both of them were considera- 
bly thickened; we could easily remove from them 
many membranous layers, some of which were gelati- 
nous. The greater portion of the left lung present- 
ed marks of inflammation; the right lung was healthy. 

The force of the fall, which this patient sustained, 
was probably one of the principal causes of the lesion 
of the aorta. In fact, from this time, the least exer- 
cise produced dyspnoea, and embarrassment of the 
circulation. Many of the symptoms which appeared 



DISEASES OF THE AORTA. 97 

later, such as violence of the beatings of the hearty 
the vibrating pulse, announced a state of hypertro- 
phy of the left ventricle. This energy of the arte- 
rial system was calmed by blood-letting; and we have 
not forgotton that if the beatings of the heart lose 
their force, they are felt in a greater extent of the 
chest, as if they had gained in extent, what they had 
lost in strength. 

The inflammation of the pleura and pericardium, 
which complicated the disease of the heart and aorta, 
and much increased its severity, proceeded in that 
slow, insidious and obscure progress, which so fre- 
quently baffles the researches of the physician. Ne- 
vertheless, the anxiety of the last moments, the jacti- 
tation, and the necessity of inclining the head on the 
chest, would perhaps have made us suspect the exist- 
ence of pericarditis, because these symptoms are al- 
most constantly present in that phlegmasia. 

Case XXXVI. 

Dilatation with Alteration of the Descending Thoracic Aorta; 
Aneurismal Tumour of the same Artery. 

Anthony Leblanc, aged 56, porter, of small sta- 
ture, pale, feeble and thin, entered the hospital Co- 
chin the 25th of October, 1821. We could not ex- 
amine him till the month of January, 1822, when he 
said he had been sick for four months only. He had 
a frequent cough, followed by mucous sputa, floating 
in a frothy liquid; he did not then spit blood, but 
had some time before; his respiration was so difficult, 
that he often feared suffocation; his voice was Iow ; 

13 



98 DISEASES OF THE AORTA. 

the chest gave a flat sound at the right side, where 
respiration was almost gone; night sweats existed; the 
pulse was small and frequent. (Expect. Jul. gum.) 

On the following days, sharp pleuritic pains were 
observed, the oppression was distressing, and the pa- 
tient longed for death. Marasmus became extreme, 
the expression of the face was dissolved, the voice 
extinct, and the patient died on the 10th of Fe- 
bruary. 

Inspection of the Body, thirty-six hours after 
death. — Chest. The costal cartilages are completely 
ossified; the left side is more sonorous than natural; a 
considerable quantity of gas escaped, at the first in- 
cision. The visceral pleura adhered to the costal, 
by a false membrane; pellicular on its internal sur- 
face; organized, and very vascular on its external sur- 
face; easily detached, exhibiting an admirable net- 
work of red vessels beneath. The corresponding 
lung, swelled with blood, was red, and stuffed with 
large tubercular, mobile, rolling masses. The right 
side gives a flat sound, and is filled with a serous, red 
liquid, about two pints or less in quantity; the lung 
pressed upward and inward, properly speaking, atro- 
phied; it does not contain any tubercular excavation, 
but is full of granulations, either opaque, or begin- 
ning to soften; it adheres to the parietes of the chest, 
excepting at its anterior part, which is free, and 
immersed in the liquid spoken of. This portion is co^- 
vered with false membrane, of a beautiful red colour, 
and of a fibrinous nature, streaked either with ves^ 
sels already well developed, or simply, with red glo- 
bules. The bronchia} and their branches are red. 
The heart, about the size of the fist, is flabby, and 



DISEASES OF THE AORTA. 99 

soft; the left ventricle, a little dilated, contains clots 
of blood; the right, very thin, is also a little dilated. 
The left auricle, sufficiently strong, is contracted; 
the right, on the contrary, having thin transparent 
walls, is dilated, and the columnse, separated from 
each other, leave intervals, in which we only per- 
ceive the serous membrane, crossed by some thin mus- 
cular fibres, so delicate, that they merit, for the most 
part, the name of capillaries. The orifices and their 
valves are in a healthy state: that of £ustachius is 
very distinct. 

The curve of the dilated aorta offers a caliber of 
twice the natural size; and presents, externally, pro- 
trusions very similar to those of the coecum ; each of 
the three principal cavities of which would contain 
a small nut, and are situated in front toward the right. 
The cavity of the aortal curve contains, at its com- 
mencement, a lamellated coagulum, two inches long, 
an inch broad, and half an inch in thickness. The 
arterial parietes are very thin, in the situation of the 
elevations described. The internal membrane is 
strewed or raised by grayish plates, of various size, 
irregularly disposed, spare and solitary, or confluent 
and agglomerated, of a fibrocartilaginous, calcarious, 
or almost steatomatous nature, separated by slight de- 
pressions, from whence results an appearance of 
roughness: this alteration extends to the trunks, 
which arise from the convexity of the curvature, and 
ceases about the middle of the carotids. The tho- 
racic aorta, generally, is dilated, but immediately be- 
hind the heart, it forms an aneurismal dilatation, as 
large, at least, as the organ itself. The tumour is 
more developed behind and toward the left; is irre- 



100 DISEASES OF THE AORTA. 

gularly ovoid; and has not contracted any close adhe- 
sion with the surrounding parts, but is united by cel- 
lular bands to the oesophagus, to the bronchial gan- 
glions, which are much enlarged, and to the origin 
of the bronchia: the neighbouring vertebrae have not 
undergone any change. The aneurismal cyst is filled 
with a lamellated coagulum, forming a hollow cylin- 
der, unequally thick at its anterior and posterior 
walls : there is, in fact, only a few fibrinous layers in 
front, while behind they are very numerous. The 
blood is found in contact with the most recent layers: 
when these are macerated, or, as it were, washed, 
they present a grayish white colour, separated by 
plates of bright red, formed of globules of arterial 
blood, transformed into vessels, or at least perfectly 
imitating them by being disposed in a regular series, 
and a diverging form. The surface, immediately in 
contact with the blood, is membranous, smooth, and 
creased with wrinkles, which give it an aspect resem- 
bling that of the internal surface of the vagina. The 
parietes of this fibrinous canal are an inch or more 
in thickness, backward: the most recent laminae ad- 
here to the others only at some points, and are, if we 
may so say, floating: they are so much the more con- 
densed the nearer they are to the walls of the aorta. 
At the same time, the external cylinders are longer 
than the others, and their length diminishes thus gra- 
dually to the most internal : from whence it results, 
that the tube formed by the conjoined cylinders, has 
a pyriform figure; very thick in the centre, thin, and, 
as it were, sharp at the extremities : its different lay- 
ers adhere to each other by a flaky and almost woolly 
texture: their corresponding surfaces are unequal. 



DISEASES OF THE AORTA. 101 

slightly rough and rugged. The aneurismal sac, dis- 
engaged from the fibrinous mass which has been de- 
scribed, did not present a projecting border, which 
commonly indicates the place where the coats of the 
artery have been ruptured: the walls of this sac, very 
thin, throughout transparent in some points, and deep- 
ly disorganized, offer, on the interior, a reticulated 
appearance analogous to that of the ventricular 
cavities, a kind of fibrinous network, the numerous 
columns of which are separated by small depressions, 
which appear to appertain to the bruised middle 
membrane, and, so to speak, perforated with erosions. 
The most minute dissection has demonstrated that 
the three coats of the dilated artery were included 
in the composition of the cyst. The abdominal aorta, 
as well as a portion of the thoracic, were equally di- 
lated in the whole of their circumference, the iliac 
and pelvic arteries offered plates of the same kind as 
those already described above; some of them, a line 
thick, and calcarious^ had elevated and even torn the 
internal membrane. 

In the preceding cases, the dilatation existed 
without being accompanied with a lamellated coagu- 
lum; in this, on the contrary, the dilatation coincides 
with the formation of a very large coagulum, present- 
ing, in some of the layers, manifest traces of organiza- 
tion. 

Farthermore, in all these cases we may remark a 
constant lesion, consisting of an alteration of the in- 
ternal membrane, or even of the whole structure of the 
aorta. From what we have said in the preceding 
chapter, the nature of this alteration can be no longer 
4oubtful; it is certainly inflammatory. 



102 DISEASES OF THE AORTA. 

The facts we have related are examples of dilata- 
tion of the whole cylinder of the aorta : we shall now 
proceed to present a case in which the dilatation was 
lateral, and prove that this kind of aneurism, denied 
by a celebrated surgeon, can no longer be called in 
question. 

Case XXXVII. 

Strong and sonorous Pulsations under the Sternum, and the 
Cartilages of the first Ribs of the right Side; Ordinary 
Symptoms of Disease of the Heart. — True Aneurism of the 
Substernal Aorta ; Ossification and Ulcerations of the same 
Artery; Hypertrophy, with Dilatation of the left Ventricle. 

John Hivet, terrace-maker, aged sixty-five, not very 
strongly constituted, of middling stature and form, hair 
ash-coloured, entered the Cochin hospital the 28th of 
November, 1822. He suffered, for three years, pal- 
pitations, and stifling, which he attributed to fre- 
quent catarrhal affections, with which he had been 
affected; a new bronchial catarrh, which he had con- 
tracted in the month of September last, obliged him 
to keep his bed; and since that period he could no 
longer attend to his laborious occupation. The phe- 
nomena which he presented, on entering, were the 
following. Complexion of a pale yellow; heaviness 
of the head; vertigo, stunning, numbness of the lower 
limbs, so great that the patient thought them dead; 
cough with thick mucous glutinous sputa; sentiment 
of weakness in the epigastric region, with tendency 
to sickness; oppression on the least exercise; pulse 
irregular, unequal, intermittent; without harmony 



DISEASES OF THE AORTA. 103 

with the beatings of the heart; tongue rather humid, 
yellow in the middle, red on the edges, inappetence, 
and sometimes nausea. 

Auscultation. — The murmur of respiration is heard 
very distinctly in the whole circumference of the chest; 
the pulsations of the heart are heard of equal force in 
the whole extent of the chest: those of the ventricles, 
explored in the precordial region, are very unequal, 
intermittent, clear and sonorous, but of moderate im- 
putation: among the feeble pulsations, active sudden 
contractions, are observed analogous to the spring of 
a bow. Under the sternum, and the cartilages of the 
first sternal ribs of the right side, simple pulsations, 
accompanied by a very clear, almost clanging sound, 
are heard, mingled with a peculiar hissing. The 
contractions of the auricles are plainly heard towards 
the clavicles; but can only be distinguished very 
confusedly in the region of the heart. 

Diagnosis. — Aneurism of the substernal aorta, 
hypertrophy with dilatation of the ventricles of the 
heart. 

Prescription. — Till, orang. Jul. digit: pedil. synap. 
The following days the patient was better; the 
sleep was tranquil, the pulse less regular, and in a 
state of repose, respiration appeared not in the least 
embarrassed. The 8th and 9th of September, con- 
siderable oppression renewed; the heart beats the hand 
which explores it by a large surface; the beatings of 
the left ventricle, less irregular than at its entrance^ 
are accompanied by a hissing sound which appears 
to be only the reverberation of that which exists un- 
der the sternum and the cartilages of the ribs spoken 
of. — The tinct. of digitalis was gradually augmented: 



104 DISEASES OF THE AORTA. 

on the 14th of December, he took sixty-five drops. — 
On the 19th of the same month, the patient presented 
signs of mental alienation, and the face, singularly dis- 
composed, exhibited a stupid smile. 

(Digitalis omitted.) 20th, Mental alienation still 
more evident; patient imagines he is going to be shot; 
and says, tranquilly, with an air of positive conviction, 
that he sees arranged all the preparations for his 
punishment: he asks pardon of all the world, &c. — 
During the whole of the same day, he imagined also 
that he was at a fishing in his own country. The 
pulse was slow, but very irregular: from time to time 
several pulsations w T ould follow close upon each 
other: — 

On the 21st in the morning, this kind of tranquil 
delirium continued; the cheeks were highly injected, 
the eyes brilliant, which induced us to bleed in the 
foot. 

In the evening the patient appeared more com- 
posed, his face less discoloured; notwithstanding, 
he was more and more persuaded of approaching 
death. 22d. — Face wrinkled, entirely discomposed, 
air of stupid astonishment, unmeaning smiles, torpor. 
23d, at the morning visit, the patient seemed to have 
regained the use of his reason : but he had fever, the 
face was injected, the tongue dry and a little coated, 
skin warm, (till, orang. soup.) The rational moments 
did not last long; in fact, when they brought him his 
soup, he refused to take it, under pretext that they 
wished to poison him; and it was with great difficulty 
that they could persuade him. 24th, 26th, 27th, 
reason was perfectly re-established : the patient, who 
recollected his wanderings of mind, could not con- 



DISEASES OF THE AORTA. 105 

ceive how he could have committed them. 28th, 
and 29th, reason entire; the patient only complains 
as usual of weakness and oppression; says he has 
taken cold, and refers the seat of his disease, under 
the sternum, where the spits are, he says, adherent. 
The following days we returned to the use of digitalis. 
11th January,, 1823, considerable oppression, white 
opaque adhesive sputa: change in the general ap- 
pearance. 13th, reason again subverted, the patient 
thinking he saw cannons pointed at him. — Finally, 
on the 14th, he died at seven o'clock in the morning, 
after long continued rattles. 

Inspection of the Body 9 fo7iy-eight Hours after Death. 

1st. Exterior appearances. — No infiltration, red- 
ness of the under surfaces from pressure. 

2nd. Respiratory and circulatory organs. — The left 
side of the chest contains at least a pint of red-coloured 
serum. Each of the lungs is crepitant throughout; but 
the left, compressed by the effusion, is much less vo- 
luminous than the right: the mucous membrane of the 
bronchia is red. — The pericardium is injected. — The 
heart, divested of the enormous clots which it con- 
tains, is more than one-third larger than the fist of 
the subject; the right cavities offer nothing remarka- 
ble, excepting the redness of their internal membrane. 
The left cavities were dilated to such an extent that 
the aortic ventricle, three times larger than the pul- 
monary, might contain a goose egg; its w r alls, towards 
the base, are about six lines in thickness; the corres- 
ponding auricle, equally dilated, is manifestly hyper- 
trophied. No remarkable lesion of the orifices. — In 
the* whole substernal portion, the aorta dilated iu 

14 



106 DISEASES OF THE AORTA, 

every direction, forms an ovoid tumour about the 
size of the fist; the aneurismal sac, composed of three 
arterial coats, contains a fibrinous white clot, which 
is not divided into distinct concentric layers, placed 
one upon the other; the arterial walls are thickened, 
and, if we may so say, hypertrophied. The portion 
of the pericardium reflected on the origin of the aor- 
ta and cellular membrane of this artery, are red and 
injected: the internal membrane is, as it were, crib- 
bled with ulcerations, separated in many points; un- 
derneath it is a pultaceous grumous atheromatous 
yellow matter; in other respects, this membrane is 
easily separated from the others; in the rest of its ex- 
tent, the aorta, manifestly, preserves its usual caliber, 
but its walls, hard and thickened, creak under the 
scalpel: the internal surface is, as it were, plated 
with cartilaginous or calcarious laminae, some of which 
have torn through the internal membrane, and pre- 
sent themselves bare in the midst of the blood: we 
meet, besides, with numerous ulcers, many of them 
very deep and of a black colour; others, more super- 
ficial, affecting only the internal membrane, which, 
even in the intervals, is unequal and rough. The alte- 
ration extends to the arteries immediately arising from 
the aorta, and diminishes the orifices of those which 
arise from the convexity of the curve in an unequal 
manner. 

3d. Abdominal organs. — The portion of the perito- 
neum which covers the last circumvolutions of the small 
intestines, and the corresponding abdominal surface is 
covered by a pellicular false membrane, of a yellow co- 
lour, and perfectly resembling concrete pus : the cir- 
cumvolutions themselves depressed into the cavity of 



DISEASES OF THE AORTA. 107 

the pelvis, are deep red on the exterior. The mucous 
membrane of the stomach is spotted of a bright red 
colour, which contrasts with the whiteness of that of 
the duodenum. The small intestine contains a li- 
quid, reddish bloody matter analogous to the lees of 
wine; its mucous membrane, somewhat soaked with 
this fluid, is of a deep red colour; its capillary ves- 
sels are admirably injected, and form very minute 
ramifications almost throughout; the mucous mem- 
brane of the folds of the ilium, is covered by a gray- 
ish layer, which adheres to it rather strongly, and 
resembles entirely the false membrane w T hich existed 
on the corresponding peritoneum. The texture of 
the intestine, almost faded, may be torn with great 
facility. The mucous membrane of the large intes- 
tine is rose-coloured. 

4th. Encephalic organs. — The membranes are 
slightly thickened, and of rather a milky colour; the 
cerebral ventricles contain a large quantity of whitish 
serum. 

Case XXXVIII. 

Simple Pulsations very strong, accompanied with the Bellows 
Sound in the Region of the Sternum, and Superior Lateral 
part of the right side of the Chest; ordinary Symptoms of Dis- 
eases of the Heart. — Eno?*mous Aneurism of the Substernal 
Aorta without rupture of its Membranes, very considerable Hy- 
pertrophy of the Heart. 

Peter Pinion, aged 35, mattress-maker, of. a san- 
guine bilious temperament, chesnut coloured hair 
and strong constitution, entered the hospital Cochin 
the 20th of May, 1823. He suffered for many years 
a difficulty of respiration, particularly noticed during 
exercise when a little violent; this was accompanied 



108 DISEASES OF THE AORTA, 

by pulsations of the heart, to which, at other times, 
he paid little attention. These symptoms had become 
more considerable within three months, and were 
complicated with gastric symptoms, for which some 
leeches were applied. 

State of the patient at his entrance. — Face livid, 
leaden coloured and swollen; infiltration of the extre- 
mities, particularly the left; speech interrupted, or- 
thopnea, insomnia, starting in sleep; pulse regular, 
without frequency, developed, hard and vibrating in 
the right arm, very small in the left, cough, viscous 
sputa; tongue moist and white* 

Auscultation. — Mucous rale in almost the whole 
of the chest; simple pulsations very strong; sibilant 
under the middle and superior part of the sternum, 
and under the cartilages of the first ribs of the right 
side as far as the clavicle. The bellows sound is heard 
very distinctly in the precordial region, and obscures 
the sound of the ventricles; the contractions of which, 
isochronous with the simple pulsations indicated, 
raise up the cylinder rather forcibly. 

Diagnosis. — Aneurism of the ascending aorta, hy- 
pertrophy of the heart; bronchial catarrh (a bleeding 
of three pallets. Ptis. aperit jul. tinct. Digital.) 

Bleeding diminished the oppression a little. 23d. 
Three days after entrance, return of dyspnoea; ex- 
treme anxiety, sensation of an inconvenient weight 
in the precordial region and towards the xyphoid 
cartilage; prickling of the limbs, abdomen in good 
order. Following days some melioration, face less 
livid, respiration more free, same state of the pulse, 
beatings of the jugular veins isochronous with those of 
the carotids; the patient can rise and eat his half por- 



DISEASES OF THE AORTA. 109 

tion; goes up stairs with much difficulty, and is obliged 
to stop at every step. 5th of June, in the evening, pa- 
roxysm of violent dyspnoea; almost convulsive contrac- 
tions of the common respiratory muscles, simultaneous 
or more properly speaking synergical contractions of 
the muscles of the neck, lower jaw and alse of the 
nose; impending suffocation, livid face, cold sweats, 
(bled ^ xii.) night sufficiently tranquil; two following 
days some r.elief. 8th, New paroxysm, (bled ^ xii.) 
again relieved. 9th, at half past eleven in the even- 
ing, a most terrific attack. The patient in continual 
fear of approaching suffocation, the hands supported 
on the bed, the face decomposed and covered with 
cold sweat, the eyes dull and staring, the mouth 
gaping, the nostrils dilated, struggling apparently 
with all his strength against the obstacles opposed 
to respiration, beatings of the heart strong, resemb- 
ling the blows of a hammer; all the arteries beat with 
violence, and the eye can distinguish the pulsations 
of the upper extremities in almost their whole course. 
Blood-letting was resorted to: but the vein furnish- 
ed only a small quantity of thick, black blood, which 
dribbled away and coagulated almost immediately. 
We prescribed a foot bath and sinapisms. Finally, 
after some hours the patient recovered his usual 
health. 11th, oppression renewed, (blister to the 
chest. ) Until the 20th, little change. The hand ap- 
plied over the region where the pulsations were no- 
ticed, feels very distinctly a kind of vibratory tremor. 
From the 20th to the 25th, the expression altered more 
and more; oedema invaded the right arm, the pulse lost 
its vibration; the patient is so oppressed, that he can- 
not pronounce two words in succession; he has no 
longer strength to sustain himself, and the body, 



110 DISEASES OF THE AORTA. 

obeying the laws of gravitation, falls on the bed, after 
lifting him up; he no longer has any appetite for food; 
finally, exhaustion of strength and oppression is in- 
creased; the patient in the reclined posture slides to 
the foot of the bed: his eyes are dull, humid, and in- 
animate, respiration is at every moment on the point 
of leaving him; he died on the 2d of July, at half past 
one, while attempting to drink half a glass of wine, 
left him by his parents. 

Inspection of the Body, twenty Hours after Death.* 

External appearance. — Body robust, enormously 
infiltrated, flat sound in the region of the sternum, 
and at the right side. 

2d. Circulating and respiratory organs. — The 
sternum and the ribs are without alteration. Each 
cavity of the pleura contains about half a pint of 
bloody serum. The heart, three times as large as the 
fist of the subject, and the substernal aorta, dilated to 
the size of a full grown foetal head, occupied nearly 
three quarters of the thoracic cavity. The heart is 
situated transversely, and contains an enormous quan- 
tity of blood; it is rounded, or rather formed like a 
pouch, and its texture appears firmer at the left, than 
the right side; its vertical diameter is about five 
inches, and its transverse is about eight. Its vessels, 
very large and swollen, ramify on the surface, where 
they form a plexus consisting of a great number of 
branches. Emptied of the clots of blood, it still re- 
tains an extraordinary size. The left ventricle de- 
scends lower than the right, its cavity is enormous, 
and might contain the fist; its walls towards the base 

* See plate 11th. 



DISEASES OF THE AORTA. Ill 

are eight to nine lines thick; they collapse after the 
incision, from their own weight. The muscular pil- 
lars are very numerous and very large; their texture 
is a little yellow, reddens and becomes vermilion co- 
loured, on exposure to the air. The left auricle re- 
verted offers a capacity somewhat less than one-third 
that of the ventricle; its walls are increased in thick- 
ness, and its internal membrane red. The mitral valves 
are healthy. The right ventricle is dilated, without 
augmentation or sensible diminution of thickness of its 
walls, but with considerable development of its fleshy 
columns. The right auriculo-ventricular orifice is 
much dilated, its valves are red, as well as the internal 
membrane of the cavities which it separates, redness is 
deeper than that of the left cavities. The interventri- 
cular septum participates in the hy pertrophia of th e left 
ventricle, to which it appears properly to appertain. 
The substernal aorta, dilated as far as the origin of the 
vessels of the curvature, forms an aneurismal tumour, 
irregularly ovoid, the dilatation being much less in the 
posterior, than in the lateral and anterior walls. This 
tumour projects and seems to lay within the right 
side of the thorax, where it corresponds to the four 
first ribs and their cartilages; it is composed of the 
three arterial coats, uniformly dilated, and much 
thickened. The internal coat is of a very deep red, 
which is prolonged into the remaining portion of the 
aorta, and many of the branches which arise from 
it; it is strewed with small ulcers, and an infinity of 
calcarious or yellow cartilaginous laminae, situated 
beneath its proper texture, some of which are never- 
theless denuded in the arterial aneurismal cavity. 
This is filled with enormous clots of blood, not dis- 



112 DISEASES OF THE AORTA. 

posed in concentric layers, but confusedly aggrega- 
ted, and for the most part recent; some of them are 
more ancient, and have a fleshy appearance. The 
aneurismal tumour terminates by an insensible and 
gentle graduation towards the left subclavian, and is 
slightly knotted at the surface. 

On leaving the subclavian, the aorta resumes its 
natural caliber, but offers along its internal membrane 
some yellow plates of commencing ossification. The 
lines are, for the most part, crepitant, and slightly 
swollen; and so compressed by the heart and the aor- 
tic aneurism, as to be pushed up against the clavicles 
and ribs. Their mucous membrane is red, and co- 
vered with thickened mucus. 

3d. Abdominal organs. The spleen and liver very 
large, and swollen with blood. The texture of the lat- 
ter is reddish brown; an infinite number of blackish 
points on it are observed, which appear to be nothing 
more than the blood, which, at first merely excreted, 
has become in some way combined with its texture: 
to this pathological state of the liver, might be given 
the name of hepatic apoplexy. The gastro-intestinal 
vessels are also swollen with blood, and from this pas- 
sive congestion results a deep redness of the mucous 
membrane of the stomach and the intestines. 

Let us glance, for a moment, at the preceding ob- 
servations, and ascertain whether it would have been 
possible to have distinguished aneurism of the aorta 
without the assistance of auscultation : to resolve this 
problem, let us recapitulate the principal symptoms 
observed. 

In the first patient, the symptoms were palpita- 
tions, difficulty of breathing while in exercise, verti- 



DISEASES OF THE AORTA. 113 

go, tendency to fainting, undefinable sensations in 
the epigastrium; very irregular pulse, not harmo- 
nious with the pulsations of the heart. But these va- 
rious symptoms are common also to many other dis- 
eases, and do not fairly announce any thing more than 
obstruction of the circulation and respiration. The 
characters of the pulse, which seemed at first to be a 
very valuable symptom, did not prove to be so. For, 
besides that they are observed in many cases, we may 
remark that they were not present at all in our second 
patient. In this one, the phenomena w r hich authors 
regard as those which belong to what they vaguely 
call aneurism of the heart, were present to their full 
extent. It is evident that no one of these phenome- 
na indicated in a positive manner dilatation of the 
aorta. By confining himself to ordinary methods of 
explanation, the physician would have announced an 
aneurism of the heart, and would have explained all 
the symptoms observed, by the existence of that dis- 
ease, while, in fact, they w T ere in part produced by 
the compression of the lungs, and the disease of the 
heart itself was very probably consecutive to that of 
the aorta. He would have thus taken, as not unfre- 
quently happens, the effect for the cause. The symp- 
toms, then, which we have enumerated, would not 
have been sufficient for us to have recognised aneu- 
rism of the aorta; but we wish that they had been 
sufficient for the diagnosis; although they never could 
have indicated to us in what position of the aorta the 
aneurism had its seat. We may rest assured, then, 
that in both patients we may justly refer the honour 
of the diagnosis to the practice of auscultation. How- 
ever this may be, the two cases concur, with a great 

15 



114 DISEASES OF THE AORTA. 

number of similar ones, to demonstrate how much the 
doctrine of Scarpa, relative to the formation of the 
aneurismal cyst, is at variance with the process of na- 
ture. The existence of true aneurisms, without rup- 
ture of the arterial membranes, is proved by such 
numerous and authentic facts, that we can scarcely 
conceive how the opinion of the celebrated surgeon 
of Pavia should find partisans. It is equally certain, 
that the internal and middle coats of arteries may be 
ulcerated, without an aneurismal sac being necessa- 
rily and actually formed at the expense of the sur- 
rounding cellular tissue. This erosion did, in fact, 
exist in many points of the aorta, in our two patients, 
and yet such kinds of cysts were not met with. It 
is true, that if the patients had lived a longer period, 
an aneurism might have formed according to the me- 
chanism described by Scarpa; that is, by an infiltra- 
tion of blood under the peri-arterial tissue. 

In the mean time, let us compare the observations 
on aneurism with rupture of the internal and middle 
coats of the aorta. 

Case XXXIX. 

Aneurism of the Substernal Aorta, voith Rupture of the Coats r 
and Communication of the Sac vrith the Trachea, prodia > 
fatal Hemorrhage. — Aortitis. 

Girardeau, aged thirty-six, carter, of middle size r 
and athletic constitution, entered the hospital La Pi- 
tie, on account of extreme difficulty of respiration, 
which augmented in such rapid successions of parox- 
ysms, that he was threatened with instant suffocation. 
These kinds of accessions resembled pretty nearly 



DISEASES OF THE AORTA. 115 

spasmodic asthma: they were accompanied with a 
stridulous sound perfectly resembling the peculiar 
sound heard when children are attacked with the 
croup. This disease was regarded as an aneurism of 
the heart, although no pain had existed in the pre- 
cordial region, and the patient had never complained 
of palpitation. 

, The principal treatment consisted of frequent ab- 
stractions of blood by leeches or the lancet, which 
constantly procured relief. The patient, getting 
wearied, left the house where he had passed the 
months of February and March, resumed his usual 
occupation, which he was soon compelled to abandon, 
and was afterwards admitted to the hospital Cochin, 
the 4th of May, 1821. On the day before his entry, 
there supervened, in the course of an access of cough, 
t vomiting of a large quantity of blood, which lasted 
only a few minutes, but which was so abundant as to 
fill four wash-hand basins. A physician, called at 
the moment, immediately opened the veins of the 
arm and foot, and allowed the blood to flow until syn- 
cope. The hemorrhage was promptly arrested. On 
recovery, the patient complained of great pain in the 
chest. On entrance, respiration was also much im- 
peded, but we did not think it proper to prescribe a 
new bleeding, on account of the smallness of the pulse, 
and the enormous quantity of blood lost the day be- 
fore : we confined hinitto very strict diet, and demul- 
cent drinks. 

On the night of the 4th and 5th instant, the patient 
was taken suddenly with extreme difficulty of respi- 
ration, rending pains, and very acute pain in the 
course of the bronchia. MM. Lecore and Courtis 



116 DI9EASES OF THE AORTA. 

students of the hospital, wished to bleed him; but he 
refused, saying he had no more blood. The pulse 
was very weak, and the face remarkably pale. Two 
cups applied to the chest, and some time after a large 
sinapism allayed the pain. 

On the morrow, the patient coughed a little, and 
complained of pains in the chest. (Emuls. elect.) 
The day was quite calm; but in the night, towards 
one o'clock, he was again taken with spitting of a 
large quantity of blood, violent dyspnoea and loss of 
speech, and died a short time after, the mouth and 
nostrils filled with clots of blood. 

Inspection of the Body. — Under the superior and 
middle portion of the sternum, which was slightly 
eroded, was a tumour of a brown colour, about the 
size of a hen's egg: this tumour was formed by the 
dilatation of a portion of the aorta, comprised between 
the origin of that artery, and the commencement of 
the vessels which proceed from the curvature; its 
anterior portion corresponded to the sternum, and its 
posterior to the trachea. 

On opening the tumour at its anterior part, we 
observed several fibrinous layers placed over each 
other, of the colour of baked meat, which could be 
separated with the greatest ease. The lamellated 
coagulum had the same consistence as far as the cen- 
tre; but at this point we found an almost liquid layer 
of black blood, separated from the solid part by a kind 
of black and injected membrane. The aneurismal 
sac having been completely emptied, we recognised 
at first an opening communicating between it and the 
aorta. Toward the middle part of the posterior wall 
of the tumour, we saw an irregular opening, with un- 



DISEASES OF THE AORTA. 117 

equal and frangous edges, which communicated with 
the trachea, and was about four lines in length, and 
two in breadth. The perforation of the trachea was 
formed at the expense of the membrane between the 
cartilaginous rings. 

A great quantity of coagulated blood was observed 
in the trachea, mouth and larynx; the lungs contained 
none of it, and were healthy, as well as the heart. 



Case XL. 

Aortitis zvith Aneurismal Tumour ■, which opened into the (Eso- 
phagus. 

John Francis Guerin, blacksmith, aged twenty-six, 
of a strong constitution, had never been affected with 
disease, excepting in the winter of 1804, when he 
was taken with a tertian fever, which continued six 
months. One day in the month of May, 1805, while at 
work, he all at once became suffocated; and going out 
as quickly as possible, vomited a considerable quantity 
of black and coagulated blood : he soon returned to 
his shop, resumed his painful labour, and continued it 
for fifteen days, although his strength had very sensi- 
bly diminished, and he had suffered from want of rest, 
oppressed breathing, and pains in the stomach, chest 
and back. The physicians of his country (Monthe- 
ry) not being able to discover his disease, gave him 
a great variety of remedies, which produced no relief. 
One of them thought he was affected with enlarge- 
ment of the great and small lobes of the liver, and 
prescribed for him accordingly. The patient, alarmed 
at his condition, which became every day more and 




118 DISEASES OF THE AORTA. 

more serious, had himself conveyed, the first of Au- 
gust, 1805, to the hospital Cochin, in a wagon, the 
jolting of which hurt him very much. He present- 
ed the following phenomena: respiration was embar- 
rassed; he felt a fixed and constant pain in the middle 
of the back, and front of the chest; which increased 
by pressure on the pit of the stomach. The expression 
of the face was much changed; pulse frequent and 
rather hard; anxiety was extreme; appetite gone; skin 
hot, halituous; bowels free. 

On the third day after entrance twenty leeches were 
applied to the most painful part of the chest. This was 
followed by some relief, the cough was moderated as 
well as the dyspnoea; the pulse retained its force and 
frequency. Next day the patient complained of 
having suffered a good deal during the night; his re- 
spiration was very laborious; and the rattles had 
already commenced. About two o'clock in the after- 
noon, after having remained some time about, and 
been assisted to walk in the hall Guerin, retired to 
bed, placed himself in the sitting posture, coughed, 
spit some blood, fell backward upon his pillow, in three 
successive motions, grew pale, had a kind of syncope, 
hiccup, and rattles, and died in about ten minutes. 

Inspection of the body. — The lungs were volumi- 
nous, and perfectly healthy. The pericardium con- 
tained about six ounces of turbid serum, mixed with 
small albuminous flakes, of a slight green colour. 
The internal surface was covered with a somewhat 
thin albuminous layer, and the portion which was re- 
flected on the heart, was covered with a firmer adven- 
titious coat, presenting on the anterior part of the 
right ventricle, and from the origin of the pulmona- 



DISEASES OF THE AORTA. 119 

ry artery, two or three white patches, of a cartilagi- 
nous appearance. 

The heart almost completely void of blood, present- 
ed nothing remarkable; the aorta was healthy as far 
as the middle part of the curvature, where its con- 
cavity presented an opening, the edges of which were 
unequal and apparently lacerated. The cleft gave 
passage to the blood, which filled the aneurismal sac. 
This was capable of containing a large hen's egg, 
and laid up against the bodies of the 3d and 4th dor- 
sal vertebrae, which were not altered; it was co- 
vered anteriorly by the trachea and esophagus; its 
internal surface was coated with fibrinous layers, so 
much the more dense as they were nearer the surface. 
Torn on its anterior lateral right side, it present- 
ed an opening capable of receiving the fore finger^ 
the esophagus adhered to this point of the aneurism, 
and was also perforated, so that the cavity of the 
aneurismal sac communicated freely with that of the 
duct, by means of which a considerable deposition of 
blood took place into the stomach: this was sepa- 
rated into two portions, the one serous, and the other 
fibrinous, the latter, or the clot, weighed about three 
pounds. The small intestine was also filled, in almost 
its whole length, with coagulated blood. 

This termination of aneurism of the aorta is very 
rare. The beautiful work of Morgagni, so fruitful 
in facts of every kind, does not contain a single exam- 
ple belonging to that celebrated observer; but he 
offers one borrowed from Matanus: unfortunately, the 
case is remarkably concise : it is as follows : — 

" Nondum dimidium mensis Aprilis, anni 1755, iij- 
ceperat, quo vir quidam ex aneurismate vita functus 



120 DISEASE OF THE AORTA. 

opportunam peragendarum observationum occasionum 
praebuit anatomicis. 

" Ventriculus insigni mole prseditus inventus est r 
totusque refertus, sanguine qui ex aneurismate in 
aorta constituto profluxerat. Aneurismaticus interea 
tumor, qui oesophagi parietibus adhaerebat, paulatim 
discissus, talem sibi transitum aperuerat ut permagna 
sanguinis quantitas in ventriculum ipsum delapsa 
fuerit." 

About the same period, Sauvage noticed in his No- 
sology an example of the rupture of an aneurism of 
the aorta into the esophagus, with some of the symp- 
toms which had preceded it. 

Remarks on a similar case, collected in the wards 
of M. Bourdier, by M. O'Reardon, and published 
in the Bulletin of the Medical Society of Emu- 
lation, were much more interesting in relation to 
the history of symptoms, as well as the anatomical de- 
scription; bat the author is deceived in thinking that 
he with M. Dupuytren were the only persons who 
had observed this termination of aneurism. The 
anatomical preparation confirming this mode of ter- 
mination was presented by one of our students, to M. 
Dupuytren; in fact, it is the very same of which this 
celebrated surgeon is said to have been a witness, and 
which Corvisart has reported in the second edition of 
his Essai sur les Maladies Organiques du cceur y 
{page 336.) 

Case XLL 

Aneurism of the Abdomiiial Aorta. 

A man about 37 years of age, an old soldier, of a 
strong constitution, was admitted into the Hospital 



DISEASES OF THE AORTA. 121 

Cochin. Attempting one day, as he told us, to leap 
across a rather wide stream, his foot slipt, and he fell 
on the opposite bank, which occasioned him to make 
a violent exertion to prevent himself from falling; 
acute pain supervened in the dorsal region, which 
neither repose nor frictions would alleviate : several 
physicians were consulted, all of whom considered 
the disorder as rheumatic, and recommended baths, 
stimulating frictions, and applications of wool to the 
affected parts. These means were useless, the pa- 
tient was sent to Aix-la-Chapelle to take the sulphur- 
ous dash, which appeared to increase the pain; the 
face was pale, thin and pinched, the appetite feeble, 
and the bowels indolent. 

M. Dejaer, principal physican of the military hos- 
pital of Liege, at that time attached to the hospital 
Cochin in capacity of house physician, has noted this 
disease in his case book, under the title of chronic 
lumbago. 

On the day after his entry, on the appearance of some 
gastric symptoms, we prescribed an emetic, which 
was taken with repugnance. The patient vomited 
freely, and in the midst of efforts raised a little blood. 
From this moment he became extremely discouraged, 
and seemed to foresee the disastrous consequences of 
the vomiting. The expression of the face was pro- 
foundly altered; the pulse became weak, and some- 
what irregular; there was also a little spitting of blood; 
respiration was more and more embarrassed, and 
death occurred on the day after the administration 
of the emetic. 

Inspection of the Body. — The abdominal aorta was 
affected with aneurism, just where it leaves the dia- 

16 



122 DISEASES OF THE AORTA, 

phragm. This artery presented a rounded opening, 
which communicated with an enormous tumour mount- 
ing up, across the aortic opening, and obtruding con- 
siderably into the posterior mediastinum. The sac 
which surrounded this tumour was filled by fibrinous 
layers placed over each other, as is usually met with 
in chronic aneurism: the pleura covered the chest, 
where it presented, and, at its superior part, had a 
rent which allowed a great deal of blood to escape 
into that cavity, 

L8B XLIL 

Aneurism of the Thoracic and Abdominal Aorta, with Erosion 
of the Arterial Pan U r . — Hydropericardium, <5*c. 

Lelong, lock-smith aged, 40, of an athletic con- 
stitution, had suffered rather an acute pain for two 
years in the region of the right kidney. At the be- 
ginning of the year 1804 his strength had diminished, 
and there supervened at this period a bilious habit, 
with spitting of mucous substances mixed with blood, 
which determined him to enter the Hotel Dieu. 
Two bleedings arrested the hemoptysis in a few days; 
but the weakness increased, the face became (Edema- 
tous, and Lelong left that hospital in a state of suffering 
and debility, which constrained him a short time af- 
terwards to enter ours. It was at the commencement 
of the year 1805. He complained of a constant rather 
acute pain extending along the region of the kidneys; 
the pulse was full, hard and frequent. 

We bled the patient, and prescribed mucilaginous 
drinks with nitrate of potass. 

But these means did not produce any change; the 



DISEASES OF THE AORTA. 123 

pain became, on the contrary, more acute toward the 
end of the month, and extended sometimes in the 
course of the right sciatic nerve. 

On the 9th of March, there supervened in the 
right side, towards the 8th and 9th ribs, a very acute 
pain, which appeared to diminish that in the lumbar 
region, both increased on pressure. 

On the 10th, the lumbar pain became suddenly in- 
tolerable, and tears of anguish were extorted from the 
patient, who said he suffered from nervous spasms of 
the muscles of that part, which it was impossible to 
ascertain by the touch. An anodyne draught pro- 
cured some relief, and a little sleep. 

On the 12th, after a warm dispute with his wife, 
this man cried out suddenly, that his pain was insup- 
portable. We again had recourse to anodynes; never- 
theless, in about an hour, he grew pale, or rather 
yellow, and desired to go to the closet, but could not 
satisfy the want of nature; his pulse became excessive- 
ly rapid, quick, less strong and less developed; the 
skin became the seat of a dry and pricking heat, af- 
terwards he was taken with hiccup and convulsions, 
made violent and useless efforts to vomit; finally, his 
face was covered with cold sweat, and he lost his 
senses. Replaced in bed, he soon revived and com- 
plained in a feeble and dying tone, that the whole 
lower half of the body was paralyzed.* The thighs 
and legs were smartly pinched, without producing sen- 
sation; the pulse became gradually weaker, the words 
died on his lips, he seemed to fall into a sleep, in fact, he 



* This Paraplegia appears to us to be owing to an interruption of the 
course of the blood in the Abdominal Aorta, 



124 DISEASES OF THE AORTA. 

slept for some minutes, but it was a sleep from which 
he never awoke. 

Inspection of the body. — The left cavity of the 
chest contained several ounces of limpid citrine 
serum. The lungs were healthy, excepting that we 
found, in each of them, at the superior part, a tuber- 
cle in the second stage of development, about the 
size of a filbert, and on the surface of that part some 
appearance of a cicatrix. 

The pericardium contained about sixteen ounces of 
limpid greenish serum, and in other respects was 
healthy. The cavities of the heart were almost en- 
tirely free of blood. The walls of the left ventricle 
were evidently thickened, and its cavity was about a 
third larger than in the natural state. The pulmona- 
ry artery, the aorta, and the branches proceeding 
from it were healthy. 

The descending aorta presented on its left side, 
about two inches above the diaphragm, an aneurismal 
sac about the size of a hen's egg. The artery commu- 
nicated with this sac by an oval opening, the greatest 
diameter of which corresponded with the course of that 
vessel, and was about an inch in extent. The internal 
and middle coats were torn, everted, and partly de- 
stroyed, and the external had concurred with the sur- 
rounding cellular tissue to form the aneurismal sac, the 
walls of which were firm, consistent, about a line in 
thickness, and smooth on their internal surface. 

On opening the abdomen, nearly a pint of bloody 
serum was evacuated. The whole fatty tissue which 
covers the peritoneum posteriorly, the gastro-hepatic 
and gastro-splenic omenta, and a part of the mesen- 
tery, appear infiltrated with a large quantity of black 



DISEASES OF THE AORTA, 125 

and coagulated blood. In the region of the right 
kidney we discovered an oblong tumour, equal to the 
size of the head of a child ten years old, covered with 
a very thick layer of coagulated blood. This layer 
being raised, the kidney appeared of its natural state, 
and raised by a mass of a fleshy appearance, which 
was, in fact, a second aneurism four or five times 
larger than the first. This aneurism was enveloped 
by the right pillar of the diaphragm, and the superior 
of the psoas muscle of the same side, which had been 
very much distended, and formed on the outside and 
in front of it a kind of muscular coat. Its cavity was 
filled with fibrinous concretions, more consistent the 
nearer they were to the external surface. Its exter- 
nal side presented a large cleft, through which the 
blood had flowed into the adjoining cellular tissue; 
its posterior side corresponded with the quadratus 
lumborum muscle : the internal surface exhibited two 
other openings : one of them, the largest, and poste- 
rior, adhered closely by the edges to the right side 
of the bodies of the first and second lumbar vertebrae, 
worn rather deeply, without any lesion of the inter- 
mediate fibro-cartilage. The other was of an oval 
form, passing in the direction of the aorta, at the in- 
ternal and posterior part of which it was placed, and 
formed the communication of the tumour with that 
artery. The greatest diameter of the opening was 
about an inch and a half in extent. On examining 
its edges, we saw portions of the fibrous coat, which 
was everted and adherent to the aneurismal sac, with 
which they seemed to be confounded in some places: 
underneath, the aorta was about one quarter smaller 
than in the natural state. 



126 DISEASES OF THE AORTA. 

The various morbid lesions which we have ob- 
served, have not presented during life any positive 
signs of their existence. 

After the post mortem examination, it was easy to 
explain the pain which the patient had suffered in 
the region of the kidney and different parts of the 
chest; but these pains, while the patient was alive, 
might have been attributed to very different causes 
from those which really produced them. 

What is still more astonishing, is, that the patient, 
examined frequently with every possible attention, 
and observed at the hospital for several days, did not 
present any symptom of organic disease of the heart 
which was revealed on opening the body after death. 
For, hardness of the pulse, rather a constant symp- 
tom of hypertrophy of the left ventricle, isolated from 
every other symptom, is not sufficient to establish the 
diagnosis. 

We find a case in Morgagni very analagous to the 
preceding.* 

* Letter 40, page 389, (trad, de MM. Desormeaux et Destouet) 



DISEASES OF THE AORTA* 127 

ARTICLE II. 

General History of Dilatation and Aneurism of the Aorta. 



SECTION L— FORMATION AND ANATOMY OF THE 
VARIOUS KINDS OF ANEURISMS. 

1. Of Dilatation of the whole Circumference of the Aorta* 

We have seen, in the first chapter, that one of the 
effects of inflammation of the aorta is the loss of the 
natural elasticity and resistance of its walls; proper- 
ties much more developed in the middle than in the 
other membranes. This effect is precisely the con- 
dition which most favours the dilatation of the arte- 
rial tube. All the world knows that the column of 
blood which flows in the aorta is propelled by a dou- 
ble motion; one of which takes place parallel to the 
axis of the vessel, while the other takes place per- 
pendicularly or obliquely to that axis, and tends to 
separate the opposite walls of the artery. It is by 
virtue of the resistance and elasticity of its tissue, 
that the aorta preserves its natural caliber, amid the 
efforts which tend to enlarge it. But from the mo- 
ment that inflammation has deprived this tissue of its 
power of reaction, dilatation is easily effected, and its 
extent augments in direct proportion to the energy 
of the dilating powers, and the weakness of the re- 
sisting walls. We see, then, that the phlegmasia of 
the arterial texture which accompanies the dilatation, 
is one of the principal elements. The dilatation of 



128 DISEASES OF THE AORTA. 

which we are speaking here, occupies the whole cir- 
cumference of the aorta. We have seen it extend 
nearly the whole length of this artery, although it is 
situated most commonly in the ascending portion and 
curvature of the aorta. The walls are thickened as 
well as dilated, and we may observe all the changes 
in them which we have described in the preceding 
chapters. The dilatation is sometimes enormous, so 
that the aorta is double, triple, or even quadruple its 
natural size, and has a somewhat striking resemblance 
to the arch of the colon: this resemblance is more 
perceptible, because the exterior of the artery fre- 
quently presents bulgings analagous to those of the 
intestine above mentioned. The internal depressions 
correspond to these projections, and in the situation 
of these sinuses the walls are thinned and semitranspa- 
rent. We may conceive, indeed, that these cavities, 
these partial dilatations, are the first degree of an 
aneurism by rupture, which ends by being engrafted 
in some mode on the dilated artery. We thought we 
should be able to distinguish the general dilatation of 
the aorta from the proper aneurismal dilatation by 
this circumstance, that the first is not accompanied 
by a lamellated coagulum. This distinction is not 
without foundation: although it is not entirely beyond 
dispute, in the individual of Case XXXVI. we found 
a coagulum, which formed a true fibrinous cylinder, 
without the presence of which the blood would have 
effused through the ulcerations of the aorta with 
which the walls of the aorta were perforated. In this 
case the dilatation was puriform, and situated on the 
descending pectoral aorta. 



DISEASES OF THE AORTA. 129 

2. Of Lateral and Partial Dilatation of the Aorta, or the true 
Aneurism of Authors. 

Sometimes the aorta, instead of being dilated in its 
whole circumference, is only so in a portion of more 
or less extent. This partial dilatation constitutes the 
true aneurism of authors; and is met with, ordinarily, 
on the substernal aorta, and curvature of that artery. 
The anterior and lateral parts of the vessel are the 
seat of the dilatation, while the posterior wall either 
scarcely participates in it, or does not participate in 
it at all. The dilatation is sometimes so voluminous, 
that it equals the size of the full-grown foetal head. The 
tumour generally inclines towards the right side of 
the thorax. We have been able to dissect easily the 
three arterial coats in most cases of this kind : they 
have constantly presented to us traces of phlegmasia, 
such as osseous plicae, redness, atheromatous suppu- 
ration, ulcerations, &c. We have found in the cavity 
of the aneurismal sac portions of coagulum, irregular- 
ly aggregated, and seldom arranged in layers. To 
understand the formation of this aneurism, it is suffi- 
cient to admit that there is less resistance in the di- 
lating parts, or a disposition more favourable to the 
action of dilating causes. 

3. Of Aneurism by Ulceration of the Parietes, or false Aneurism 

of Authors. 

Aneurism by ulceration of the internal and middle 
coats, is the only one which the illustrious Scarpa 
will admit. We have proved that true aneurism is 
not a pure chimera, as the celebrated surgeon of Pa- 

17 



130 DISEASES OF THE AORTA. 

via pretends, but a disease confirmed by positive ob- 
servation. We shall add, that it is only by a kind of 
abuse of language that we can allow the name of aneu- 
rism to the affection which we shall presently describe, 
since this last does not consist in dilatation, but de- 
struction of the parietes, and, consequently, in a tu- 
mour of blood to which the surrounding parts (so to 
speak) extend an envelope. Ulceration, in this case, 
is the principal disease, whilst the formation of a sac, 
called aneurismal, is only an accident, the same as in 
primitive false aneurism. The wound of the artery 
is the principal disease, and the epanchcmcnt of blood 
is only a circumstance or symptom attending it. It is 
to be desired, that wc do not confound under the 
same denomination afTections entirely different; and 
that the expression of aneurism, reduced to its ety- 
mological signification, should be exclusively appro- 
priated to distinguish dilatation of the arteries. 

The mechanism of the formation of what we calL 
aneurism, by rupture of the walls of the aorta, is easy 
to comprehend. When the internal and middle mem- 
branes have been destroyed by an ulceration more or 
less extensive, the blood, endowed with a lateral 
movement, gradually elevates the cellular membrane, 
is infiltrated into the surrounding parts, distends 
them, is accumulated, and ends by forming a tumour 
more or less voluminous. The experiments made by 
Nicholls before the Royal Society of London, and re- 
peated by a great number of authors, have proved 
that when the internal and middle membranes of an 
artery are separated, and we inject water or air into 
the vessel, the external membrane swells in such a 
manner as to form a small aneurismal sac: so that when 



DISEASES OF THE AORTA. 131 

the internal and middle coats are destroyed, the cel- 
lular membrane sustains the whole lateral pressure of 
the blood, and when the resistance is overcome, it 
becomes distended, and expands in such a manner as 
to constitute a sac in which the blood accumulates. 
In the mean time, the distention continually making 
progress, the cellular membrane opens of itself, and 
the sheath of the vessel arrests in its turn the effusion 
of blood; finally, when the sheath has also yielded, 
the surrounding parts, whatever be their texture, 
concur to the formation of the sac. The internal in- 
flammation, the first source of all the phenomena, is 
communicated successively to all the surrounding 
parts; rendering them thicker and more fragile, and 
effects an adhesion in consequence of the lymphatic 
matter which it produces. Such is the mode in which 
the sac is formed in cases of ulceration of the arterial 
coats. 

It happens that the sac is produced in a somewhat 
different manner. The calcarious plates of which 
we have so often spoken, tear and cut after a certain 
manner, in some cases, the internal layers of the aor- 
ta: from which results a cleft, or narrow separation, 
in which the blood is infiltrated, to afterwards raise 
the cellular membrane, and form a true cyst. In a 
case of this kind, M. Laennec has seen the cellular 
coat separated from the others, or, more properly 
speaking, dissected to a great extent, from the origin 
of the descending aorta, to the origin of the primitive 
iliacs, the external coat was dissevered from the fibri 
nous, in such a manner that at first sight one woul 
» •frjhave been led to believe that the canal of the aorta 
had been divided by a central partition. This very 




132 DISEASES OF THE AORTA. 

singular case of dissected aneurism of the aorta is the 
only one with which we are acquainted.* We have 
only found infiltrations circumscribing ulcers of the 
aorta, or surrounding clefts produced in the manner 
above mentioned. At the opening of the body of 
George II. , king of England, Nicholls observed a si- 
milar accident. The aorta presented a transverse 
fissure, about an inch and a half long, through which 
a little blood had quite recently passed under the ex- 
ternal coat, and formed an elevated ecchymosis.f M. 
Hodgson has also made the same observation. It is 
in general in the transverse direction that the coats 
of the aorta are destroyed : it may, nevertheless, be 
longitudinal or circular. 

The cases in which aneurism has been produced 
in the mode described, have been very numerous. 
We may consult, in this respect, the researches of 
Lancisi, Guatani, Morgagni, Desault, Warner, Scar- 
pa, Home, Hodgson, &c. 



% .4P 



*' 



r . 



4. Uf Mixed Aneurism. 






Pathologists understand by this term an affection 
which consists in a dilatation of the arterial parietes, 
followed by rupture, and epanchement or effusion of a 
certain quantity of blood beneath the cellular mem- 
^/*|torane, which it distends to the form of a sac. As its 
name indicates, it is a combination of the true and false 
aneurism of authors. A great number of aneurismal 
.umours are formed in the following manner : The 
es begin to undergo a dilatation, in which all 

* Auscult. Mc 




l£ 






* Auscult. Med. tome II. p. 411. 

•j- Philosophical Transactions, &c. vol. LU. p. 269. 





DISEASES OF THE AORTA. 133 

the coats participate : but, after a certain time, the 
internal and middle coats open, and the external, 
which is the most extensible, is alone concerned in 
the formation of the sac* We have never had oc- 
casion to notice the variety of aneurism, observed by 
Haller, MM. Dubois and Dupuytren, in which the 
internal coat of the artery, dilated, produces a her- 
nia through the internal and external coats, and con- 
stitutes the aneurismal sac. 

Whether the sac, succeeding the destruction of 
the arterial parietes, has been preceded or not by 
their dilatation, it communicates into the cavity of 
the aorta by an opening narrower than its base, cir- 
cumscribed by a kind of external strangulation. This 
disposition of parts has been perfectly described by 
Scarpa, and is represented with great fidelity in the 
plates appended to his excellent work on aneurism. 

Corvisart has given out an opinion on the mode of 
development of aneurism, which is too valuable to be 
passed over. It is founded on two cases which he 
has collected relative to this subject. In the first, he 
found a tumour about the size of a nut at the anterior 
part of the aorta: it was formed by a fibrous cyst, 
the walls of which were about two lines in thickness, 
and contained a substance less consistent than tal- 
low, and of a deep red colour, much like the coagula 
of blood, a long time formed, which adhere to the in- 
terior walls of aneurismal sacs. The external layers 
of the aorta, at the place corresponding to the cavity 
of the cyst, were destroyed, and the thickness of the 
walls were in this place, especially, infinitely less 

'* This is the mixed external aneurism of authors. 







134 DISEASES OF THE AORTA. 

considerable than in any other point." Corvisart 
could not perceive any communication between this 
cyst and the cavity of the aorta; he saw only a gray- 
ish livid spot, corresponding to the base of the cyst. 
A tumour perfectly similar, but rather less volumi- 
nous, adhered to the aorta, below the coeliac artery. 
In the second case, merely quoted by the same au- 
thor, two or three tumours perfectly resembling the 
preceding were seen on the ventral aorta; the primi- 
tive iliacs presented also each one or two. From 
these facts, Corvisart thinks that if the patient had 
lived some time longer, the tumours would have en- 
tirely eroded the walls of the artery; and that then 
"the blood could have passed more freely into the 
cavity of this cyst, suddenly transformed into a tu- 
mour of blood." This opinion, or rather this hypo- 
thesis, appears to us scarcely probable. The facts 
related by Corvisart seem more proper to prove one 
of the most happy terminations of aneurismal tumours, 
and in which, after the absorption of the greater part 
of the coagulum, the tumour is transformed into a 
kind of fibrous knot. Mr. Hodgson, who cites in his 
work the facts quoted from Corvisart, regards them 
as proofs of this mode of the spontaneous cure of aneu- 
rism, and we heartily coincide in his opinion, which 
he confirms by cases and observations of his own. 

We have shown above how the external coat, more 
extensible than the others, is involved in the forma- 
tion of the aneurismal sac. Accordingly, it would be 
sufficient to prevent this formation, to deprive the 
aorta of its cellular coat. Nature herself has per- 
formed the same experiment. In fact, the aorta, at 
its commencement, strengthened by a fold of the pe- 



DISEASES OF THE AORTA. 135 

ricardium, is deprived of the cellular coat; conse- 
quently, the destruction of the coats, at this point, 
is followed by a perforation and epanche?nent of blood 
in the pericardium, and the formation of an aneuris- 
mal sac does not occur. 

In proportion as an aneurismal tumour augments in 
volume, it envelopes all the neighbouring parts, ap- 
propriates them to itself, and forms, by means of 
them, a kind of cyst. The membranes, the muscles, 
the bones themselves, concur to form the sac : the 
viscera fulfil analogous functions when the disease is 
situated in the thorax, or in the abdomen; and the 
coats which enter into their structure have been dis- 
tended beyond measure, the sac opens at last into 
their cavity. At other times, it is not by an immo- 
derate distention, but by the propagation of inflam- 
mation, that the aneurism breaks. However this may 
be, it is by rupture into the lungs, bronchia, esopha- 
gus, stomach, intestines, bladder, &c, that aneurisms 
become frequently fatal. It results, from all these 
considerations, that the volume of the aneurismal tu- 
mour depends on the nature of the parts which sur- 
round it, their greater or less extensibility, the quan- 
tity of cellular tissue which they contain, &c* This 
is the reason why aneurism of the arteries of the en- 
cephalon is so extremely rare, and that a lesion capa- 
ble of determining this disease in other parts, is here 
followed by an apoplexy more or less serious. 

One of the most remarkable phenomena w r hich ge- 
nerally accompanies the formation of aneurism, is the 
accumulation of a portion of the fibrin'e of the blood 

* In Case XLII. the volume of the tumour equalled that of the head of a 
child ten years old. 



136 DISEASES OF THE AORTA. 

in the interior of the sac* This kind of deposit, or 
crystallization, takes place in successive layers, con- 
centrated or placed over each other, resembling, in 
this respect, those which enter into the composition 
of urinary calculi, but with this difference, — that in 
these the internal layers are formed first, while the 
contrary takes place in aneurismal coagula. The la- 
minae which concur to the formation of a coagulum, 
very nearly resemble flesh which has been disco- 
loured by ebullition. In our thirty-sixth case, we 
observed in the concrete mass of blood evident traces 
of organization. The layers most recently deposited, 
macerated (so to speak) in the blood, had a grayish 
white colour, disseminated in patches of a bright red, 
formed of red vessels disposed in a plexus: the sur- 
face in immediate contact with the blood had a po- 
lished appearance, membraniform, and wrinkled, 
like the internal surface of the vagina; the most re- 
cent laminae, adhering to the others only at some 
points, were almost floating; but the layers were aug- 
mented in density in proportion as they were exa- 
mined nearer the aortic walls, and they adhered to 
one another by a flocculent and almost lanuginous 
cellular tissue: the most exterior were organized in 
such a manner as to form a species of fibrinous net- 
work, the aspect of which appeared very much like 
that of the interior of the ventricular cavities.* 

It is evident that the lamellous coagulum is only 
formed by the successive precipitation of a portion 
of the fibrine of the blood. It is met with more fre- 
quently in aneurisms by rupture than aneurisms by 

* Consult the interesting sketches of Sir Everard Home, on the organiza- 
tion of coagula of blood, in the Philosophical Transactions. 



DISEASES OF THE AORTA. 137 

dilatation: nevertheless it may happen, and we have 
furnished examples in which no coagulum is found in 
the first, although they are present in the second; 
but, in general, true aneurisms contain simply clots 
of blood confusedly aggregated, and without any de- 
terminate arrangement. 

We cannot explain the formation of aneurismal co- 
agula, excepting by the stagnation of the blood in the 
aneurismal sac. It is demonstrated by observation, 
that the coagulation of this liquid takes place at all 
times when its course is interrupted; thence we ac- 
count for the concretions met with in the cavities of 
the heart, in the veins and arteries, in consequence 
of an obstacle to the circulation. 

It should appear, also, that certain concretions of 
blood adhering to the walls of vessels, are produced 
under the influence of a pathological state, probably 
inflammatory, of their internal membrane; but we 
must not suppose, with some authors, that every con- 
cretion of blood supposes the existence of a previous 
phlegmasia. 

The thickness and volume of aneurismal coagula 
present great varieties: we have found them more 
than an inch thick, and as large as the two fists. 
When the coagulum exists entirely round an artery, 
its thickness is more considerable on the side where 
the aneurismal tumour is most prominent. The num- 
ber of laminae is proportionable to that thickness. M. 
Laennec has found some of these laminae so compact, 
that they had the consistence of horn softened by 
strong heat. 

Lastly, the layers which enter into the composi- 
tion of a coagulum have not all the same dimensions. 

18* 




138 DISEASES OF THE AORTA. 

In our thirty-sixth case, these layers formed con- 
joined cylinders, the most internal of which were the 
shortest; so that the extremities of the coagulum were 
thin and somewhat sharp, giving to the whole a fu- 
siform appearance. 



SECTION II. 

OF THE INFLUENCE OF ANEURISMS OF THE AORTA ON 
THE PARTS WITH WHICH THEY ARE FOUND IN CON- 
TACT. 

The mechanical effects, physiological or patholo- 
gical, which aneurismal tumours produce on the parts 
which surround them, vary according to a great num- 
ber of circumstances, among which we should reckon 
their volume, nature, and position. 

One of the most remarkable of these effects is, the 
wearing or erosion of the bones, which concur in 
some way to form the sac: these bones are the ster- 
num, the clavicles, the vertebrae, and sometimes the 
iliac bones. A circumstance rather singular consists 
in this, that the fibro-cartilaginous tissues remain of- 
ten untouched amid the destruction of the most deep- 
seated bones. Some of the old pathologists pretend, 
(what is entirely false,) that the blood acts chemi- 
cally on the bone, by virtue of which it is dissolved : 
others have attributed this effect to the impulsion of 
the blood, and the beatings of the tumour. They, 
consequently, consider the destruction of the bones 
as a kind of erosion, produced by an action purely 
mechanical. Such is the opinion of MM. Corvisart 



DISEASES OF THE AORTA. 139 

and Laennec. Hunter and Scarpa regard this kind 
of disease as proceeding from an absorption of the 
earthy matter, produced by the pressure of the sac. 
We are far from wishing to deny the mechanical in- 
fluence of aneurismal tumours on the bones; but we 
think that the destruction of these parts is not a pure- 
ly mechanical action; that it depends, also, at least in 
certain cases, on a phlegmasia of the bony texture. 
We have seen that the aneurismal aorta presented 
traces, more or less marked, of inflammation; that 
the tumour determined the same disease in the sur- 
rounding parts, and took, as it were, the precedency 
of it. But why should not the osseous texture in- 
flame like other parts? Will it be objected, that the 
intervertebral, or other cartilages, are ordinarily 
found in a state of integrity? We shall reply, that 
this phenomenon strengthens our opinion, instead of 
opposing it. The fibro-cartilages, in fact, protected 
by their pliancy and elasticity, by their almost inor- 
ganic texture, inflame with much more difficulty than 
the bones. Thus, in the caries of the knee, it is not 
rare to meet with the semilunar fibro-cartilages entire- 
ly healthy, &c. (See the Memoir of M. Cruvelheir, 
inserted in the Arch. Gener. de Med.) 

If the caries of bones were an effect purely mecha- 
nical, how can we explain why tumours very volu- 
minous, accompanied with enormous beatings, do not 
determine any alteration of the bones, whilst the con- 
trary takes place in aneurisms of the smallest size? 
This very remarkable phenomenon may easily be con- 
ceived, on the contrary, in admitting that inflamma- 
tion plays a very active part in the change to which 
we have alluded. 






140 DISEASES OF THE AORTA* 



In some cases the aneurismal tumours do not pro- 
duce an erosion of the bones, but a wasting and atro- 
phy of them, while in other cases they heave up, 
displace or disarticulate them. Thus, Corvisart has 
reported a case in which the clavicle had not been 
worn, but luxated, by the pressure of the tumour, at 
its sternal extremity. 

Mr. Hodgson says, that, in cases where the peri- 
osteum concurs to the formation of the aneurismal 
sac, its vessels continue to secrete an earthy matter, 
which has sometimes been so abundant as to envelop 
a considerable part of the tumour. 

Aneurismal tumours do not confine their destruc- 
tive effects to the bones with which they are in con- 
tact. When the alteration of these is completed, they 
distend the subjacent parts: the integuments, for ex- 
ample, become inflamed, and they protrude through 
the ulcerations which they have occasioned. Such 
is the mode in which frightful hemorrhages super- 
vene, which terminate so frequently the lives of aneu- 
rismal subjects. It is not always in consequence of 
the rupture of the aneurismal sac, externally, that 
death happens : this rupture may take place in very 
different parts, according to the seat of the aneurism. 
M. Laennec reports a case, in which an aneurismal 
tumour burst into the cells of the lungs. Frequently 
the aneurism of the ascending aorta, or of the curva- 
ture, compresses the trachea, or one of the bronchise, 
flattens or deforms them, determines an ulceration 
and perforation, and finally opens into them, pro- 
ducing suddenly fatal haemoptysis. We may add to 
the cases of authors relative to this accident, our 
thirty-ninth. We have seen, but less frequently, the 



DISEASES OF THE AORTA. 141 

aneurismal tumour make its way through a perfora- 
tion of the esophagus. When this happens, of which 
our fortieth case furnishes a remarkable example, the 
patients perish while in the act of vomiting blood. 

At other times the aneurism ruptures at the origin 
of the aorta, and determines a fatal epanchement into 
the pericardium. 

We have seen aneurisms of the aorta open into the 
pulmonary artery. MM. Payen and Zinck present- 
ed to the Society of the Faculty of Medicine an ex- 
ample of this kind : Dr. Wells has reported one in the 
Transactions of the Medical and Chirurgical Society 
of London. 

The posterior mediastinum, the cavity of the pleu- 
ra, especially the left, are the situations in which 
aneurisms of the thoracic aorta most frequently open. 
M. Laennec thinks that aneurisms, after having 
completely destroyed the bodies of the vertebrae., 
may burst into the vertebral canal. 

The same author has seen an aneurism of the de- 
scending aorta, which had compressed and destroyed 
the thoracic canal, and produced a swelling of all the 
lacteal vessels. 

We have several times seen aneurismal tumours 
exercise a good deal of compression on the vena cava, 
descendens or ascendens : it may happen, that the 
aneurismal tumour forces a passage into that vein, 
and produces what is called a varicose aneurism of 
the vena cava, analagous to those of the veins at the 
bend of the arm, or ham of the leg, &c. We are ac- 
quainted with a case, in which the pressure upon a 
group of aneurismal tumours of the curvature of the 
aorta, determines a compression of the vena cava su- 









142 DISEASES OF THE AORTA. 

perior; so that several attacks of apoplexy have re- 
sulted from it, and an (Edematous swelling of the face. 
Corvisart mentions an analogous fact. 

Whatever may be the seat of aneurismal tumours, 
it is evident that one of their inevitable effects con- 
sists in a more or less considerable compression of 
surrounding organs. In the chest, the lungs, the 
bronchise, the oesophagus, the large vessels are the 
organs on which this compression is expended. In 
the abdomen the organs are more mobile, and for the 
most part less important, and therefore retreat before 
the tumour, and suffer little from its mechanical ac- 
tion. When the tumour is developed towards the 
origin of the cceliac artery, or below it, it is arrest- 
ed, for the most part, in its progress by the pillars 
of the diaphragm, which concur to form the cyst, 
and furnish it with a muscular covering, an example 
of which has already been spoken of. 

We may readily conceive how aneurisms of the 
ventral aorta may occur amid several viscera of the 
abdomen; as, the intestines, the bladder, &c. Their 
compression on the nerves, and vessels, in their course, 
may also become the source of particular phenomena. 
An efFect still more remarkable of aneurisms of the 
aorta, is, an obliteration of an adjacent artery by the 
pressure produced on it. Sir Astley Cooper and Mr* 
Hodgson have seen, the one the common carotid, the 
other the left subclavian obliterated in this manner* 



DISEASES OF THE AORTA. 143 



SECTION III. 

OF THE SIGNS AND DIAGNOSIS OF ANEURISM OF THE 

AORTA. 

Vesalius is the first who has recognised, on the 
living, the existence of an aneurism of the aorta : he 
announced this disease in an individual having a pul- 
satile tumour near the vertebrae of the back. This 
diagnosis, truly audacious for the time, in which 
Vesalius lived, was not regarded as certain by the 
other physicians who saw the patient, until after the 
opening of the body showed them the aorta dilated 
nearly to the size of an ostrich egg — Ut ovi struthio- 
cameli magnitudinem fere acquaret. Fernel had also 
given, as a sign of aneurism of the internal arteries, 
a violent pulsation {vehemens pulsatio;) but, as Mor- 
gagni has remarked, besides that it is only on the 
part of Fernel a simple conjecture, every pulsation, 
although very violent, does not depend upon an aneu- 
rism. Also, the celebrated Baillou, as he avows with 
noble candour, could not recognise, on a certain Jean 
Formagee, the existence of an aneurism of the aorta, 
until after having opened his body : and, neverthe- 
less, this Formagee had presented, during his life, 
very violent pulsations in the hypochondrium; since 
Baillou says, that he did not recollect of ever having 
examined a hypochondrium where the pulsations 
could be so forcibly felt: JYunquam memoria sua 
tarn alte palpitant, pulsansque hypochondrium con- 
tigerat. 

If you take a survey of other authors who have 
written on the diagnosis of aneurism of the aorta, you 



144 DISEASES OF THE AORTA. 

will see that they have never been able to distinguish 
the disease, excepting in those cases in which a more 
or less prominent tumour was perceptible at the ex- 
terior of the body; and you will find, indeed, many 
cases, in which the disease was not in the least sus- 
pected during life, and some in which it was not even 
recognised after death, of which the work of Senac 
furnishes a rare example.* 

Lastly, notwithstanding the bright light spread in 
these latter days on the signs of diseases of the heart 
and lungs, the diagnosis of aneurism of the aorta re- 
mains yet shrouded in obscurity. The cases we have 
related, and the researches which we have ourselves 
made, may perhaps contribute to dissipate the rest of 
the obscurity with which medicine is troubled. 

We might distinguish the signs of aneurism of the 
aorta into such as are idiopathic or proper, and such 
as are sympathetic or remote. The first are the most 
important to ensure the diagnosis. 

According to Corvisart, whose profound sagacity 
no one can deny, the diagnosis of aneurisms of the 
aorta are always somewhat obscure, when the dilata- 
tion is not observable externally, whilst it becomes 
evident when the tumour presents itself to the eye 
and to the touch of the practitioner. But the symp- 
toms which lead us to recognise an aneurism of the 
aorta, prominent externally, are, the tumour itself, 
and the pulsations isochronous with those of the pulse, 
pulsations of expansion and elevation, which we should 
not confound with those which accompany pure and 
.simple aortitis, or which are produced by simulating 

* De la Structure du Coeur, tome H. page 339, et scriv. 



DISEASES OF THE AORTA. 145 

aneurism. It is the sign already mentioned by Ve- 
salius and Fernel. 

Let us examine, in the mean time, the signs which 
Corvisart regards as the most proper to make us sus- 
pect, or even acknowledge, the existence of aneu- 
risms, which are not as yet sensible to the sight, nor 
the touch. The following are the symptoms: — 

1. A peculiar stridulous sound when the patient 
speaks or respires. At first, this symptom exists 
only in proportion as the tumour is so placed as to 
compress the trachea or the bronchise; it is, there- 
fore, purely accidental: afterwards it may be pro- 
duced, as Corvisart has cited the example, by other 
lesions than aneurism of the aorta. * 

2. A jarring tremor sensible to the hand, found 
above the situation of the heart, while the pulsations 
of this organ are observed in its accustomed place. 
We think that this symptom merits serious conside- 
ration; it was very observable in the patient of our 
thirty-eighth case: but it appears that it is not con- 
stant, since M. Laennec had never met with it ex- 
cept in cases where the tumour was already visible 
externally; and we do not find it noticed in the 
cases observed by authors, nor even in many of our 
own. 

3. The obscurity of sound, which the superior and 
middle parts of the chest give on percussion. But 
how many other diseases may produce the same phe- 

* Some individuals affected with aneurism of the curvature of the aorta, 
complain of a dragging" sensation of the larynx; the voice becomes hoarse, 
or even entirely extinguished. Cannot these phenomena be explained by 
the pulling which the tumour produces on the recurrent nerve, which we 
know passes round the arch of the aorta? 

19 



J46 DISEASES OF THE AORTA. 

nomenon! and in how many aneurismal dilatations of 
the aorta, on the contrary, does not the chest re- 
sound, as well as in the region of the sternum? 

4. The smallness and irregularity of the pulse; 
and sometimes its inequality in both arms. However,, 
these phenomena are by no means constant; a multi- 
tude of other disorders, different from aneurism, may 
produce them; such as a morbid state of the orifices 
of the heart, and ossification of the arteries, which 
arise from the arch of the aorta, &c. 

All these symptoms cannot then be counted among 
the number of signs, in some measure pathognomo- 
nic, of aneurism of the aorta, to use the expression 
of Corvisart. In according, indeed, all the impor- 
tance which has been attached to them, is it not 
evident that they would only serve to make known 
aneurism of the ascending portion of the aorta, and 
that they would be of no value in the diagnosis of 
aneurisms of the descending thoracic aorta, and espe- 
cially the abdominal aorta? 

The result of the discussion in which we have 
been engaged is, that at the period when Corvisart 
wrote, there did not exist any sure method of ascer- 
taining aneurism of the aorta, unless it were in cases 
where the swelling could be felt externally, — cases 
which are confined to aneurisms of the ventral aorta, 
and to the small number of those of the ascending 
aorta, which, after having elevated or destroyed the 
sternum, the cartilages of the ribs, and the clavicles, 
form a more or less prominent tumour: even in these 
circumstances we might be deceived, as M. Laennec 
has shown in an example. (Be PAuscidt. Med. tome 
II. p. 437.) We could cite many examples of sinu- 



DISEASES OF THE AORTA. 147 

Jar mistakes. The symptoms indicated by Corvisart 
ought not to be neglected; we think, on the contra- 
ry, that, connected with those furnished by auscul- 
tation, they will give to diagnosis the most complete 
certainty.* 

We have seen that Corvisart regarded the diagno- 
sis as perfectly easy, when the tumour projected ex- 
teriorly, and was sensible to the eye or the touch. 
Certainly we cannot give to these senses such a de- 
gree of delicate tact, that we should be able to ascer- 
tain an aneurism, when it is hidden more or less pro- 
foundly in the interior of the abdominal cavities; but 
there is another sense, which may take the place to a 
certain degree of sight, and immediate touch : we mean 
the ear, either alone or by the aid of the stethoscope; 
and we are assured, that by means of this instrument, 
the diagnosis of aneurisms of the aorta will no longer 
present more difficulty, than that of the diseases of 
the heart, or the lungs. M. Laennec, in his work 
on mediate auscultation, expresses himself thus, in 
speaking of that ingenious mode of exploration: "I 
am not as yet satisfied to what extent auscultation 
mediate may serve to establish the diagnosis of aneu- 
rism of the aorta: I have met with few of them since 
the commencement of my researches. Some of these 
facts give the hope, and even the surety, that, in 
many cases at least, the cylinder will make known the 
disease before it has produced any serious local or ge- 
neral symptom: others, on the contrary, prove that a 

* The terebrating* pains of the back and loins, the pains, of whatever na- 
ture, which sometimes accompany aneurism, are symptoms too equivocal, 
and not sufficiently constant, to entitle them to-be considered pathogno- 



148 DISEASES OF THE AORTA. 

very voluminous aneurism of the thoracic aorta may 
exist, without the possibility of its being ascertained 
by auscultation, especially if we have not, in other 
respects, some reason to suspect its existence." Our 
cases thirty-seventh and thirty-eighth, in which we 
have recognised aneurism of the aorta, before it had 
formed a tumour externally, has forced us, in some 
measure, to advocate the use of auscultation, in op- 
position to the celebrated inventor himself. In other 
respects, perhaps, it will not be impossible to conci- 
liate our opinions. M. Laennec allows that the only 
characteristic sign, truly pathognomonic, of aneurism 
of the aorta, consists in the simple pulsations, ascer- 
tained by auscultation, in the region corresponding 
to the aneurismal tumour. By means of this sign, 
M. Laennec discovered two aneurisms of the abdo- 
minal aorta, the diagnosis of which would have been 
very uncertain by the mere application of the hand." 
It is by virtue of this sign, that the same physician 
ascertained two cases of dilatation of the ascending 
aorta. Finally, it is also by means of this same sign 
that we ourselves recognised the aneurism of the sub- 
sternal aorta, with which the subjects in cases thir- 
ty-seventh and thirty-eighth were affected. What 
can we object to these facts? As it is, properly 
speaking, physically impossible that the pulsations 
spoken of should not exist in all the cases of the same 
kind, weshould think ourselves justified in concluding 
that, by means of an exploration sufficiently attentive, 
the diagnosis will be always strictly possible. 

It is true, M. Laennec relates that it has happened 
to him three times since he has made use of the cy- 
linder, to overlook aneurisms of the substernal aorta; 



DISEASES OF THE AORTA. 



149 



but we remark, that in all these cases, the cylinder, 
as M. Laennec has taken care to observe, had not 
been applied to the sternum. These facts, far from 
militating against the signs furnished by auscultation, 
make them appear to still greater advantage, while 
they at the same time demonstrate the uncertainty 
of all the others; because, we do not doubt that M. 
Laennec would have perceived aneurism in the three 
cases in question, if he had applied the cylinder upon 
the sternum, while all the other means of exploration 
were not sufficient to enable this excellent observer 
to ascertain the disease. 

Whoever duly considers the facts and arguments 
we have advanced on this subject, will agree with us 
that auscultation offers an exceedingly valuable me- 
thod of exploring aneurisms of the aorta. But the 
simple pulsations produced by the tumour, and which 
reveal the existence of it, require that we should 
study them at present in some detail. 

When an aneurism occupies the substernal aorta, 
the pulsations are heard under the sternum, and un- 
der the cartilages of the ribs, in an extent more or 
less considerable, according to the volume of the tu- 
mour. We shall hear the pulsations so much the 
more readily, as the bony parts with which the tu- 
mour is in contact transmit, with remarkable inten- 
sity, the vibratory sounds. This circumstance, so 
favourable to their transmission, had, without doubt, 
escaped the attention of M. Laennec, when he said, 
that aneurisms of the thoracic aorta, although very 
large, might exist without our being able to ascer- 
tain them by the cylinder;* while the same method 

v Ouv. cit. tome U. page 438. 



150 DISEASES OF THE AOKTA. 

would enable us to ascertain, with the greatest faci- 
lity, aneurisms of the abdominal aorta, less favoura- 
bly situated than those of the substernal aorta, not in 
consequence of the impulsion, but of the sound the 
tumour communicated. 

Aneurisms of the descending thoracic aorta, and 
especially those which erode the vertebral column, 
manifest their existence by simple pulsations corres- 
ponding to the corroded vertebrae; a sign so much 
the more certain, as the fact has been well observed 
by Laennec, that the double contractions of the heart 
are very rarely heard in the back. 

Lastly, enormous beatings which hurt the ear, ac- 
companied with an intensity of which the hand can 
give no idea, not even when it feels them distinctly," 
existing in the region of the abdominal aorta, indi- 
cate the existence of an aneurism of that artery. 

It is important to know how to distinguish the pul- 
sations we have been speaking of from every other 
pulsation; for unless we are able so to do, the diag- 
nosis of aneurisms of the aorta will fall into that ob- 
scurity from which we are so desirous to rescue it. 
In the cases where aneurism occupies the substernal 
aorta, the beating pulsations with which it is accom- 
panied might be taken for those of the ventricles of 
the heart; but the pulsations produced by the aneu- 
rismal tumour differ from those of the heart, by the 
intensity of the noise which accompanies them, which 
is so shrill, in some cases, as to affect the ear. As the 
pulsations of the aorta, by a kind of reverberation, 
may be heard at points more or less remote, and es- 
pecially in the precordial region, and as they are 
sometimes complicated by a kind of bellows sound. 



DISEASES OF THE AORTA. 151 

we may believe in the existence of a contraction of 
the arterial orifices of the heart. Nevertheless, we 
shall readily avoid this error, in considering that 
these pulsations are much stronger in the region cor- 
responding to the aneurism, than any whcife else. 
Pulsations of the aorta, in reality, exist with charac- 
ters so determinate, that it appears to us that it would 
be difficult to mistake them when they have been 
once heard. But we must acknowledge that these 
varieties of character are very difficult to describe, 
and impossible to express; and that the ear alone, by 
a kind of. medical tact peculiar to it, is capable of 
properly perceiving and analyzing them. We have 
already said, that very powerful pulsations are some- 
times observed in the abdominal region, although the 
aorta be not the seat of any aneurismal tumour. That 
these pulsations may be the result of an inflamma- 
tion, or spasm of the aorta, or may be nothing more 
than the natural pulsations of that artery, transmit- 
ted with a kind of reaction by some abdominal tu- 
mour. We may distinguish these from the pulsations 
truly aneurismal, by the circumstance of the sound 
being much less strong, the impulse less extensive; 
whilst we can ascertain, by means of the cylinder^ 
that the aorta has neither changed in form or dimen- 
sion. The bellows sound which may accompany 
them, seems to us a character much more equivocal 
than the preceding. 

But in the mean time how can we explain the vio- 
lence of the beatings of an aneurismal artery? It 
should seem that the vessel, in dilating, ought to lose 
some portion of the vigour of its action. We can 
seldom give a satisfactory account of the phenomenon* 



152 DISEASES OF THE AORTA. 

except in admitting, as we think we have proved/ 
that the aneurism of the aorta is constantly accompa- 
nied with an inflammatory state of the walk of the 
vessel, which augments the energy of its pulsations. 
It may dlso happen, that the sound which naturally 
accompanies the motion of the aorta, undergoes a 
kind of resonance in the aneurismal cavity, more or 
less extensive, in the same manner as the voice re- 
sounds in tubercular cavities, so as to produce the 
phenomenon of pectoriloquy : whatever other expla- 
nation may be given of the pulsations of aneurismal 
tumours of the aorta, their existence is what it is 
most important for us to confirm, and what we hope 
we have done. 

It remains for us at present to take a rapid survey 
of the sympathetic and accidental symptoms of aneu- 
rism of the aorta; that is to say, of those produced by 
the influence of this disease on the other organs. 
We shall say but little on this point, the symptoms 
of which are in their nature very inconsistent, and 
of little use in diagnosis. 

Respecting the subject which here occupies us, 
we may say, there are few diseases more insidious 
than aneurism of the aorta: in many cases, in fact, 
the first notice of its existence is a frightful death, 
as sudden as that given by a pistol shot. It is in 
consequence of a rupture of an aneurismal tumour, 
that certain individuals perish whom we thought to 
be in the most perfect state of health, and who never 
complained of the slightest indisposition. 

Among the symptoms .which we shall examine 
here, should be arranged those pointed out by Cor- 
visart, and which announce the compression or alte- 



DISEASES OF THE AORTA. 153 

ration of the surrounding organs; such as stridulous 
voice, difficulty of speech, smallness and irregularity 
of the pulse, unequal in the two arms. To these 
symptoms we might add swooning, fainting and gid- 
diness; and when the tumour becomes a considerable 
obstacle to the veinous circulation in general, or to 
that of the brain in particular, apoplectic conges- 
tions, serous infiltration, more or less considerable, 
dyspnoea, &c. Some patients, as M. Laennec has 
observed, complain also of nausea and hiccough. 

Lastly, we shall conclude by recalling some of the 
phenomena, which are less symptoms and signs of 
aneurism of the aorta, than accidents which may oc- 
cur in this disease. Thus, when the tumour comes 
to open in the bronchia or trachea, the patients pe- 
rish of haemoptysis, more or less profuse. The pa- 
tient observed by M. Laennec, in whom an aneurism 
had opened into the substance of the lungs, com- 
plained of a species of ebullition at the top of the 
lung: thus, the patient in our fortieth case, in whom 
the tumour broke into the oesophagus, died in conse- 
quence of vomiting of blood: thus, the patient in the 
forty-second case, was affected, before his last mo- 
ments, with a paraplegia, in consequence of an in- 
terruption to the course of the blood, in the abdomi- 
nal aorta. Peculiar phenomena are also observed 
when the tumour opens into the bladder, the intes- 
tines, the vertebral canal, the vena cava, the pulmo- 
nary artery, &c. 

Rupture of an aneurismal tumour of the aorta is a 
terrible and often inevitable accident, ordinarily pro- 
duced in consequence of an ulceration of the circu- 
lation: hence the reason why it happens from an in- 

20 



154 DISEASES OF THE AORTA. 

tense moral affection, or any considerable effort. An 
attendant of the Amphitheatre at La Charite, who 
apparently enjoyed perfect health, died in the arms 
of his mistress, during the act of coition. On open- 
ing the body, we found an aneurism of the aorta, 
with rupture of the parietes. 

It is scarcely necessary to observe, that the symp- 
toms of such an accident are paleness of the face, 
coldness, faintness; in short, all those symptoms which 
characterize formidable haemorrhage.* 



SECTION IV. 

OF THE TREATMENT OF ANEURISM OF THE AORTA, 
AND ITS MODE OF CURE. 

A. From what we have said respecting the nature 
of this disease, it is evident that it requires the same 
therapeutic means ns aortitis itself. Also observe, a 
circumstance quite remarkable, that the most cele- 
brated treatment, which has been proposed against 
this disease, the true nature of which was not then 
known, is precisely the antiphlogistic method in all 
its force. It will be perceived that we refer to the 
method of Valsalva and Albertini. The treatment of 
Valsalva and Albertini, consists in weakening the pa- 

* The causes of aneurism of the aorta being 1 almost absolutely the same 
as those of inflammation of that artery, we shall not stop to enumerate them 
here. We shall refer to what we have already said. We would merely re- 
mark, that all the professions which require great exertions, all violent pas- 
sions in which the motion of the blood acquires an excess of velocity, ought 
to be ranked among the most powerful causes of aneurisms of the aorta- 



DISEASES OF THE AORTA. 155 

tients by diet and repeated bleedings, to such a point 
that they can scarcely draw their arms out of bed. 
Besides, that this method is so well adapted to the 
proper character of the disease, it has here another 
advantage; namely, of diminishing the impulsion of 
the blood against the aneurismal sac, and of favouring, 
in its interior, the formation of the lamellated coagu- 
lum, without the resistance of which the artery would 
break much more readily. 

Valsalva and Albertini, according to Morgagni, 
have obtained the cure of a great many aneurisms as 
well internal as external, by the rigorous employment 
of the treatment which bears their name. Morgag- 
ni, himself, Lancisi, Guattani, Sabatier, MM. Pelle- 
tan, Corvisart, Hodgson, Laennec, &c, recommend 
this method, and adduce facts in its support. We 
participate their opinion on this point, but avow, 
that if it is clearly demonstrated, that it has been fol- 
lowed by the most flattering success in the treatment 
of external aneurisms, it has not been so rigorously 
proved that it has succeeded more frequently in that 
of aneurisms of the aorta well ascertained to be such, 
and we think that the most of the cases reported by 
authors, are examples of the cure of pure and simple 
aortitis or simulating aneurisms. 

Mr. Hodgson recommends that the bleeding be not 
carried so far as to produce fainting; for, says he, the 
blood then accumulates in the aneurismal sac, and 
forms an obstacle to the circulation at the moment when 
the heart resumes its functions. He says that he has 
seen, in similar circumstances, faintings endure so 
long as to excite intense alarm. Morgagni assures 
us that he has seen them followed by death. To pre- 



156 DISEASES OF THE AORTA. 

vent such a formidable accident, we ought to bleed 
moderately, repeat it frequently, and allow the blood 
to flow by a small opening in the vein, or, what is 
better, not to apply the ligature to the superior part 
of the limb, according to the mode of M. Pelletan, 
which permits the blood to dribble slowly away. 

Perhaps we might associate, with advantage, local 
bleedings with bleedings by the lancet: this is at 
least, what we are authorized to conclude from the 
cases we have adduced in the preceding chapter, in 
reference to the treatment. 

The most absolute repose of both body and mind is 
necessary to favour the process of the debilitating 
treatment. The diet ought to be extremely sparing. 
It will be necesary to imitate the conduct of Valsalva, 
who had been accustomed, says Morgagni, after 
having taken the necessary quantity of blood, to di- 
minish every day the aliments and drinks, until he 
had given only half a pound of the first in the fore- 
noon, and a quarter of a pound in the evening, and 
nothing but water for drink, not exceeding a certain 
quantity of this liquid. After having sufficiently 
reduced his patient in such a manner as that he no 
longer had sufficient strength to draw his hand out 
of bed, where he was put at the commencement of the 
treatment, Valsalva augmented, gradually, the quan- 
tity of the aliments until the necessary strength had 
returned.* 

There are some other means proper to aid the ef- 
fects of those already spoken of. Thus we may admi- 
nister preparations of digitalis, the acids diluted in a 

* See Morgagni, Epist. xvii. art. 30. 



DISEASES OF THE AORTA, 157 

great quantity of water, and acetate of lead, from which 
M. Dupuytren appears to have obtained fortunate re- 
sults, and which we have ourselves employed with 
some success. So also we may have recourse to im- 
mersion of the feet and hands in warm water, a prac- 
tice recommended by Morgagni, with whom it suc- 
ceeded, in the case of the Marquis de Palluci, the 
history of which he has related with so much care. 
This method, undoubtedly, has a feeble and altoge- 
ther temporary efficacy, but we might employ it with 
advantage during the paroxysms of dyspnoea, which 
sometimes accompany the disease. We might also 
allow the patient some spoonfuls of sedative or ano- 
dyne julep. 

13. Whatever may have been the agents employed in 
the treatment of aneurism of the aorta, it is evident that 
none of them are able, by a direct influence, to remove 
the aneurismal tumour, and that nature alone can pro- 
duce such a result. It is a curious subject of inquiry, 
to ascertain in what manner such a process is con- 
ducted. But here is the point where it becomes dif- 
ficult to follow nature, and assert the facts of the heal- 
ing power. We have never had an opportunity to 
examine the aorta after such a cure; but it is proba- 
ble that aneurism of this artery is cured by a series 
of changes which resemble those, which happen to 
external aneurismal tumours, in the same circum- 
stances. 

We have seen in what precedes that one of the 
circumstances, which, in general, accompany the first 
period of aneurism, is the formation of a lamellous 
clot in its cavity. It appears that this deposition 
performs an important part in the process by which 



158 DISEASES OF THE AORTA. 

the disease arrives at a cure, which we call sponta- 
neous. In proportion as the fibrinous lamellae accu- 
mulate in the sac, its cavity diminishes, and its re- 
sistance to the lateral pressure of the blood augments. 
Lastly, the moment arrives when the mass of coagu- 
lum is such that it interdicts all communication be- 
tween the cavity which contains it, and the artery 
with which this cavity primitively communicates. 
At this period the sac, strengthened by the presence 
of the fibrinous layers interwoven with it, is no longer 
threatened with rupture, and nature can apply herself, 
without danger, to the work of absorption, the result 
of which is a gradual diminution of the coagulum, 
and subsequent contraction of the aneurismal sac. 
What we have said here concerning the mode, ac- 
cording to which the spontaneous cure of aneurism 
of the aorta is effected, reposes not only on analogous 
data, obtained from an observation of what takes place 
in the progress of certain external aneurisms, but 
also on the direct examination of the state in which 
the aorta is found in some aneurismal subjects. We 
have seen that in the patient of the thirty-sixth case, 
the coagulum was disposed in the form of a perfect 
cylinder, partly organized, which diminished the 
cavity of the aneurismal sac, and across which the 
blood flowed. In a man who had presented, before 
death, some symptoms of aneurism of the aorta, M. 
G. Young discovered that an aneurism had existed 
at the anterior part of the curvature of the aorta. 
" The tumour," says he, " proceeded from a circum- 
scribed opening in the aorta, having about nine lines 
in diameter; it was easy to be perceived, from the 
absence of the coats of the vessel in that extent. The 



DISEASES OF THE AORTA. 159 

sac, reduced then to the volume of a small orange, 
was filled with a lamellous coagulum the most con- 
sistent I ever have met with, which, evidently, ap- 
peared to have heen amassed at a remote period. 
The sac was almost entirely filled with that fleshy 
mass, so that it would have heen impossible to have 
opened it in any direction whatever. This coagu- 
lum did not extend into the cavity of the aorta, so as 
to obliterate it, but was disposed entirely around it, 
so that there remained a small opening which would 
have contained half a nut, and which allowed the 
blood to flow freely into the arteria innominata which 
arose from the inferior and posterior portion of the 
sac." 

A woman had died with symptoms of aneurism of 
the aorta : at the opening of the body, we discovered 
an aneurism of the aorta, about the size of a small ap- 
ple; the interior of which contained solid but very 
distinct layers of coagulum, of a white appearance, 
and more fleshy than in recent cases. The opening, 
by which the aorta had formerly communicated with 
the sac, was obliterated by the base of the coagulum. 
This did not extend, however, into the cavity of the 
aorta, the caliber of which, consequently, had not 
participated in the curative process which had su- 
pervened in the aneurism. The work of Mr. Hodg- 
son, from which we have extracted the two prece- 
ding cases, contains other similar ones. If we com- 
pare with these facts, the more conclusive ones, ob- 
served by Corvisart, w T hich we have cited, when 
speaking of the formation of aneurisms, we shall be 
convinced that this disease, even when it affects the 



160 DISEASES OF THE AORTA. 

aorta, is susceptible of a spontaneous cure, in the 
manner we have pointed out. 

The process by which the spontaneous, cure of 
aneurism of the aorta takes place, differs, however, 
from that which we observe in the cure of aneurism 
of arteries of the second and third order. In fact, 
although the canal of the aorta is never completely 
obliterated by the accumulation of the coagulum, the 
contrary is ordinarily observed in the arteries of the 
second and third order. Nevertheless, it also some- 
times happens that these arteries retain the free pas- 
sage of their canals, and that the cavity of the aneurism, 
with which they have been affected, is alone oblitera- 
ted, as we shall presently describe, takes place in the 
aorta. On this subject we may consult the cases re- 
corded by Petit, Desault, Baillie, Scarpa, Hodgson, 
Jones, Farre, &c. 

All the preceding considerations apply particu- 
larly to the spontaneous cure of aneurism by rupture 
of the walls of the aorta. As to aneurism, properly 
speaking, or aneurism by dilatation, we are ignorant 
if nature or art have ever been able to effect a cure. 
It appears to us difficult, not to say impossible, that a 
cure can ever take place in the case where the tu- 
mour has acquired a very considerable volume, such 
as to equal, for example, the fist, or even the head 
of a foetus; examples of which we have related. 

We shall not terminate this article without noticing 
the analogy which exists between the cure of aneu- 
rism of the aorta, such as we have described it, and 
the cure of a wound made either in an artery, or in 
a vein. In fact, from the researches of many mo- 



DISEASES OF THE AORTA. 161 

dern authors, and from what we have ourselves ob- 
served, it is also by the organization of the fibrinous 
part of the blood, which has diffused itself round the 
wound, at least in some eases that the cure of the 
wound is effected. This analogy is another induce- 
ment for us to consider the ulcerated state of the ar- 
terial coats, as the principal and essential disease; and 
the tumour called aneurismal, as an accident purely 
symptomatic, which nature employs in a most admi- 
rable manner to cure, though rarely, indeed, the pri- 
mitive disease of the artery. And we shall repeat 
that the word aneurism, employed in this case, ought 
to be rejected, and devoted expressly to denote the 
dilatation of arteries.* 

* We do not speak of the surgical treatment of aneurisms of the aorta, 
which is most efficacious in cases of external aneurisms. We are not 
ignorant, nevertheless, that the ligature of the aorta has been practised 
in England, by the celebrated Astley Cooper. No one applauds more 
than us the efforts which surgeons have made to extend the bounds of 
their art; but we should not advise ordinary practitioners to undertake 
the daring and brilliant operation of the illustrious surgeon of London. 



21 



162 DISEASES OF THE AORTA. 



CHAPTER III. 



OF CONTRACTION AND OBLITERATION OF THE 






AORTA. 

Science, as yet, professes very few cases in rela- 
tion to the contraction and, more or less complete, 
obliteration of the aorta. It is true that many authors 
speak, not unfrequently, of contractions of the aorta 
at its origin, especially when they do not meet with 
any other lesion, which can explain the dilatation of 
the heart which they have met with. But nothing 
seems to us less certain than the frequency of such 
contractions, considered as the cause of aneurism of 
the heart. In fact, out of about two hundred cases 
of these diseases, which we have under examination, 
we do not find a single one in which it is clearly de- 
monstrated that aneurism has been produced by such 
a cause. We do not deny that such a case may, now 
and then, occur, but we think it is a much more 
rare complaint, than is generally imagined. 

We have already said, elsewhere, that we knew a 
case in which the abdominal aorta was almost entirely 
obliterated by the enormous ossifications of its walls; 
we shall proceed to relate some other cases of the 
same kind. 



DISEASES OF THE AORTA. 163 

Case XLIII. 

A young man, fourteen years of age, subject to a 
violent palpitation, and considerable oppression, died. 
At the opening of his body, we found the heart dou- 
ble its natural size; the curvature of the aorta of a 
caliber of nearly four inches; the arteries, arising 
from the arch, were considerably dilated, in such a 
manner, that the left subclavian seemed to be the 
continuation of the aorta. The aorta descendens, on 
the contrary, was so contracted, that its caliber was 
only about four-fifths of an inch; and, six or seven 
lines below the left subclavian, it was entirely obli- 
terated for the extent of some lines, resuming, after- 
wards, its natural diameter. 

The superior intercostal and thoracic arteries, the 
mammary and inferior intercostals were dilated; the 
foramen ovale, which passed into the aorta immedi- 
ately below its contracted portion, was not only per- 
meable, but large enough to admit the passage of a 
catheter. {Journal de Medecine, par Corvisart, Le- 
roux et Boyer, tome XXXIII. 1815, Bull. No. IV.) 

Case XLIV. 

An individual fifty-seven years of age, of a robust 
temperament, had enjoyed good health for a number 
of years, excepting in the winter, when he was con- 
stantly afflicted with a severe cough. In the night 
of the 7th of April, 1809, he was affected with cough, 
and difficulty of respiration greater than usual. He 
complained of pain under the sternum; the extremi- 
ties were cold, and his anxiety was inexpressible; the 



164 DISEASES OF THE AORTA. 

pulse weak, but regular and much altered in frequen- 
cy. These symptoms continued with hardly any di- 
minution, notwithstanding the application of cup- 
ping glasses, blisters, and volatile liniments to the 
sternum, until about eleven o'clock, when he died, 
on attempting to walk a few steps to get into bed* 
On opening the body, the pericardium was exces- 
sively distended; and when laying it open, a very 
large quantity of blood flowed out One of the co- 
ronary veins, at the anterior surface of the right ven- 
tricle, was ruptured. At first, we thought that this 
might be the source of the extravasation; but, on a 
more attentive examination, we discovered an open- 
ing which conducted to the right ventricle, in such 
a manner that the rupture had begun in this part of 
the heart, and, having extended across its substance, 
had finished by taking the vein. The pulmonary ar- 
tery was healthy, as well as the left side of the heart; 
the lungs adhered a little to the internal surface of 
the thoracic cavities, and each of these contained a 
small quantity of fluid. The finger having been in- 
troduced into the aorta, opposite the place where the 
arterial canal terminates, we discovered in its interior 
a contraction, which would scarcely admit the little 
finger. We ascertained, that it was owing to a thick- 
ening of the circular fibres of the vessel, as well as to 
a partial ossification of its coats. 

This contraction of the aorta prevented the pas- 
sage of the blood across the heart and the lungs; 
and in that extreme state of distention, the right 
ventricle, keeping in view its diminished power 
of resistance, finally burst, and produced sudden 
death. (Obs. de MM. Winstone et Astley Cooper. 



DISEASES OF THE AORTA. 165 

inseree dans la traduction de Pouvrage de M. Hodg- 
son, par M. Breschet.) 






Case XLV. 



Henri Frere, aged fourteen, was admitted to the 
Infirmary, the 3d of August, 1813. Two weeks pre- 
viously, being exposed to cold, he was affected with 
a dry cough, which for eight days was accompanied 
with rather copious expectoration, and pain in the 
left side of the chest; impeding respiration, and in- 
creased by cough : the pulse beat one hundred, and 
was a little hard: transpiration was abundant. 

The disease was regarded as pneumonia so far ad- 
vanced that suppuration seemed to have supervened; 
bleeding, blisters, expectorants, and cathartics dimi- 
nished the symptoms; the pulse continued frequent, 
hard, full, but always regular. 8th, he had nausea 
and vomiting. 27th, only complained of palpita- 
tions. 6th October, left the hospital as cured: ne- 
vertheless the boy entered the hospital the 13th of 
November following, presenting very remarkable vi- 
brations of the carotid and subclavian arteries; had 
been always subject to palpitations and dyspnoea. The 
pain in the left side had reappeared soon after the pa- 
tient left the hospital, and gradually augmented. The 
pulse became regular, and beat eighty-eight a minute. 
A blister procured him some relief. 

The symptoms had diminished for a time, under 
the employment of rubefacients and cathartics; but 
the pain in the left side of the thorax returned in the 
evening of the 29th. A blister, repeated the next 
day, produced a good deal of suffering until the 2d of 



166 DISEASES OF THE AORTA. 

December, when a sudden access of fever restored 
the part nearly to the natural state. The 3d, the 
fever was dissipated; a similar access, accompanied 
with nausea and vomiting supervened on the 12th, 
and yielded immediately to an emetic. The 23d; for 
ten days he had been affected with pains in the right 
side of the chest; the pulse had risen anew. (Blis- 
ters, cathartics, two bleedings.) The blood, especial- 
ly after the first bleeding, appeared very buffy, the 
pulse was lower, and the pain removed; but the cough 
and the palpitations continued. The circulation re- 
vived again on the 27th, and remained depressed till 
death. The patient perspired frequently and freely, 
ceased to take nourishment, and was taken with vo- 
miting; the urine became sabulous, the sleep was agi- 
tated, the dyspnoea and the palpitations augmented, 
and he died the 2d of January. The pulse was al- 
ways regular, but unequal as to strength and hard- 
ness. 

Inspection of the Body. — The abdominal cavity 
contained near a pound of serum, and the intestines 
were distended with gas. The pericardium was 
much dilated, and adhered to the left pleura cos- 
talis: it contained about an ounce of fluid, and a 
heart twice as large as common for a child of that 
age. The walls of the left ventricle were about an 
inch in thickness; but we did not observe any other 
derangement in the structure of the heart or its valves. 
The capacity of the cavities of this organ appeared 
natural; the aorta was extraordinarily dilated near its 
origin, and formed a kind of pouch. After having 
furnished the branches destined to the head and the 
superior extremities, it was singularly straitened : the 



DISEASES OF THE AORTA. 167 

straightening extended as far as its union with the 
ductus arteriosus, after which the aorta became com- 
pletely impermeable, without its coats being either 
diseased or thickened : we discovered only a small 
elevation united to the internal surface, half an inch 
below the straightened part. This prominence, less 
elevated, was nearly the diameter of a pea. As to 
other appearances, it might be said that the artery 
had been firmly compressed with a tight ligature. 
The obstructed portion was about one line broad : the 
artery, afterwards, gave off three branches about the 
size of a chalk line, and, lower down, three other 
smaller branches. Lastly, the aorta resumed the na- 
tural size along the vertebrae. These three vessels 
were evidently the superior branches of the inferior 
intercostals; their coats were very thin, and resem- 
ble4 those of the veins: a sound passed from the pul- 
monary artery along the ductus arteriosus to the ob- 
structed portion of the aorta; but, from its apparent 
thickening, it did not seem probable that this canal 
had any communication, and the flourishing appear- 
ance during life favours this presumption. The ar- 
teria innominata, left subclavian, superior intercostal 
and mammary arteries were much dilated; the epi- 
gastric was of its usual size. These circumstances,, 
and the natural caliber of the aorta, immediately be- 
low the strangulation, proves clearly that the bloody 
as might have been expected, was not conveyed in 
sufficient quantity to the inferior extremities by the 
anastomosing branches of the mammary and epigas- 
tric arteries, but principally by the communications 
of the superior intercostal and mammary arteries with 
the three large branches rising from the aorta below 



168 DISEASES OF THE AORTA. 

the straightened portion, leaving out of the account 
the anastomosing branches of the mammary and tho- 
racic arteries, with the intercostal and diaphragma- 
tic. The lung had nearly its common colour, the 
left lobe was much compressed. We found on each 
side of the thorax a small quantity of bloody serum. 
( Observations of Mr. Graham, published in the fifth 
volume of the Medico- Chirurgical Transactions.) 

Mr. John Bell, in his Surgical Observations, re- 
lates the following fact : — 

Case XL VI. 

M. Paris, prosector of the Amphitheatre of the 
Hotel Dieu, injected, in 1789, the body of a woman 
about fifty years of age, whose aorta was completely 
obliterated a little below its curvature. M. Paris was 
struck with the extraordinary dilatation of the small 
arteries at the anterior part of the chest. The injec- 
tion introduced by an opening made in the aorta pe- 
netrated so easily, that, far from suspecting an obli- 
teration, M. Paris was afraid he had employed too 
large a quantity of material. The aorta, immediate- 
ly below its curvature, was reduced to the size of a 
writing quill: its coats were of unusual thickness, but 
its cavity was remarkably contracted. The curva- 
ture of the aorta, above this contraction, was but lit- 
tle dilated; the part situated below had not lost its 
natural diameter: we could discover nothing either 
in the peculiar texture of the vessel, or in the sur- 
rounding parts, which served to explain the con- 
traction. The carotids were in their natural state; 



DISEASES OF THE AORTA. 169 

the arteria innominata and the subclavian were twice 
their natural diameter : their smaller branches were 
proportionally dilated and bent zigzag. The mam- 
mary and diaphragmatic arteries, the transverse ar- 
teries of the neck, the thoracic and scapular, and all 
their branches were considerably enlarged and tor- 
tuous. Below the contracted part of the aorta, the 
inferior intercostals were triple or quadruple their 
natural size, and the largest were those which arose 
nearest the contraction; the inferior diaphragmatic, 
and epigastric arteries, were also much dilated and 
inosculated pretty freely, with the superior dia- 
phragmatic and mammary. 

We may readily conceive that it is impossible to trace 
a general history of contractions of the aorta, from the 
small number of facts, which science has collected on 
this point of pathology. What is the cause of this dis- 
ease? Is it always accidental? Is it sometimes congenital? 
Are there any signs by means of which we can recog- 
nise, or, at most, suspect it? What influence does it 
exercise on the principal organs and their functions? 
These questions, and many others which might be 
added, cannot be resolved at present in a satisfac- 
tory manner. Some of the eifects of the disease, 
however, plain reasoning, or even analogy, might 
lead us to foresee, if the preceding observations 
have not already, in part, revealed them. Thus, 
for example, the obstacle placed in the way of 
the blood, in contraction or complete obliteration of 
the aorta, must occasion an enlargement, and species 
of irritation in the vascular system situated behind 
it. Hence, the dilatation of the arterial trunks, 
which arise from the aorta; the dilatation and hyper* 

22 



170 DISEASES OF THE AORTA. 

trophy of the cavities of the heart, and even their 
rupture, as appears to have taken place in the case of 
Sir Astley Cooper; thence the congestions more or 
less violent in the encephalon, especially if it should 
happen that the obliteration was brought about very 
rapidly, instead of forming by degrees, so that nature 
prepares, insensibly, new channels for the blood which 
the aorta refuses to receive, as it happens in all cases, 
of the same kind, for example, in the cure of aneu- 
risms. 

We do not think there exists any mode of recog- 
nizing the disease which occupies us. We are igno- 
rant, indeed, if the extraordinary development of the 
arteries, which serve for the anastomotic and collate- 
ral circulation, joined to the absence of the ordinary 
signs of the other obstacles to the aortic circulation, 
would suffice to make us suspect the existence of con- 
traction or obliteration of the aorta, a lesion, which 
we suppose always to have its seat below the curva- 
ture. However it may be, one of the consequences, 
the most remarkable which we may draw from the 
preceding facts is that nature, even in these cases, 
in her immense resources is the means of keeping up 
the circulation in the parts situated below the co-ac- 
tion or the complete obstruction of the aorta, the 
principal canal, from whence the blood is distributed 
through all the organs. Another consequence, re- 
sulting immediately from this conclusion, is that the 
ligature of the aorta, such as Sir Astley Cooper has 
performed, would be an operation truly practicable, 
if there was not opposed to it any other objection, 
than the fear that the transmission of blood, in the 
inferior parts, was impossible by means of the anasto- 



DISEASES OF THE AORTA. 171 

motic vascular system. What observation demon- 
strates in man, experience, on living animals, con- 
firms. In fact the celebrated surgeon whom we have 
just mentioned, has frequently tied ligatures on the 
aorta of dogs, and the blood has not been less easily 
transmitted to the posterior limbs of these animals by 
the anastomosing branches. The same author ob* 
serves, in his memoir on the ligature of the aorta, 
translated by M. Breschet, that there is at the Hos- 
pital of Saint-Thomas an admirable preparation, 
showing the aorta obliterated (on an animal,) and the 
numerous and dilated anastomoses, which continue 
the circulation. 

We shall not advance any farther reflections on the 
disease which forms the subject of this chapter. We 
fear we should err by endeavouring to go beyond the 
facts: We should stop as soon as the light of observa- 
tion ceases to guide us, or as soon as we have lost the 
thread of experience to guide us in our researches. 
We proceed to consider another kind of contraction, 
much ljore common than the preceding, of which we 
hope to be able to present a more complete history- 



172 DISEASES OF THE AORTA. 



CHAPTER IV. 

OF THE INDURATION AND VEGETATIONS OF THE 
VALVES OF THE HEART, AND CONTRACTION OF 
ITS DIFFERENT ORIFICES. 



PRELIMINARY CONSIDERATIONS. 

The physicians of the present day are well ac- 
quainted with the fact ; that the orifices of the heart 
are surrounded by fibrous zones, to which the mus- 
cular fibres are attached, which constitute the pro- 
per texture of the heart. These fibrous rings are, 
properly speaking, the tendons of this muscular or- 
gan; they send prolongations to the valves, and thus 
communicate with the tendinous cords of the fleshy 
ventricular columns. All these peculiarities, ob- 
served by some ancient anatomists, have been better 
described by the moderns, and especially by M. 
Gerdy. The fibrous tissue of the orifices and valves 
of the heart, is invested by the internal membrane of 
that organ ; which, according to Bichat, very nearly 
resembles serous membrane. We may, therefore, 
employ, with Corvisart, the name of fibro- serous tis- 
sue, to express the nature of the texture of which 



DISEASES OF THE AORTA. 173 

the valves and white zones are composed, which en- 
circle the auriculo-ventricular orifices. The tissues 
of this nature are distinguished from all others, by the 
extreme facility with which they are converted into 
a cartilaginous or even osseous substance, we should 
not be astonished, therefore, to find the valves and 
the valvular rings of the heart frequently the seat of 
fibro-cartilaginous, or even ossiform degenerations. 

Although many ancient and modern anatomists have 
been occupied, with advantage, in the study of these 
transformations, it is still highly necessary that this 
interesting subject should be farther investigated. We 
regret, especially, that many of the pathologists who 
first made known some of the valvular lesions, have 
not described them more exactly, and, subjoined to 
their description, the history of the symptoms, which 
they had observed during life. Thus, in revising 
the authors who have frequently furnished the illus- 
trious Senac with the very brief cases which he 
cites in his beautiful work, we cannot form an exact 
idea of these fleshy concretions, glandular bodies, 
and callosities of which he has so vaguely spoken. 
And, notwithstanding the rapid progress which pa- 
thological anatomy has made in our days, we have no 
precise idea of the nature, mode of formation, cha- 
racter, and signs of the indurations to which we al- 
lude. 

Ossification of the valves of the heart, as well as 
those of the arteries, is frequently met with in a more 
or less perfect state, in people of advanced age; but 
does it follow, as the classic authors have pretended, 
that it is the effect of the pathological affection, which 
has been sufficiently explained in the preceding 



174 DISEASES OF THE AORTA. 

chapters. Does it not also occur in youth, and even 
infancy? 

We shall now proceed in our attempt to add some- 
thing to what has already been said on this point of 
pathology. We shall commence, according to our 
prescribed rule; first, to present the facts, then to 
compare and analyze them, and, finally, compose a 
general history. We shall present, in succession, ex- 
amples of induration, and vegetations of the right 
and left cavities of the heart. 



ARTICLE I. 

Observations on Induration and Valvular Vegetations* 



SECTION L— INDURATION OF THE VALVES, 
Case XL VII. 

Hardening and Thickening of the Bicuspid Valve, and of its 
fibrous Zone: Calcarious Concretion of the Apex of the Heart, 

Josephine Wagner, aged forty-seven, cook, mar- 
ried at twenty, mother of two children, born in Ger- 
many, of parents who died of acute disease, suffered, 
for a great many years, difficulty of respiration when- 
ever she took the least fatiguing exercise. Some 
time after menstruation had ceased, which took place 
at the age of forty-five years, she felt under the ster- 
num an erosive pain, with heat or cold according to 
circumstances. At the same time a slight cough ap- 
peared. About a year afterward, the strength had 



DISEASES OF THE AORTA. 175 

sensibly diminished, the inferior extremities and the 
loins became (Edematous, the abdomen also was swol- 
len, which determined the patient to enter the hos- 
pital Cochin, the 4th of December, 1805. At that 
time, respiration was laborious and plaintive; there 
was pain under the inferior portion of the sternum, 
weakness, cough, with mucous expectoration, ema- 
ciation, and intermittence of the pulse; which was 
frequent, small, depressed, presenting the third or 
fourth pulsation more sensibly than the rest, (Ptis. 
pect. jal. id.; pot. calm.) 

The substernal pain remains, the dyspnoea aug- 
ments at intervals; sometimes there is a slight cepha- 
lalgia in the evening; the cough is accompanied with 
rather copious expectoration of viscid matter, mixed 
with a kind of purulent secretion, of a cherry colour, 
tinged with brown; analogous to what results from a 
small quantity of blood diffused in the mucous sub- 
stance: the pulse continues to be intermittent, and 
scarcely sensible. 

19th, weakness greater, abdomen sensible to slight 
pressure, cough fatiguing, with diminished expecto- 
ration : watchfulness the night following. 

20th, face depressed, eyes dull, voice almost ex- 
tinct, expectoration of a deep gray fluid, thirst. 

21st, nearly the same state; tongue drier, the pa- 
tient complained of total loss of strength : in fact, she 
died about one o'clock in the morning. 

Inspection of the Body. — On opening the thorax, 
about a wine glass full of bloody serum flowed from 
the left cavity; old adhesions were observed between 
the corresponding folds of the pleura. The mucous 
membrane of the bronchise, uniformly reddened, was 



176 DISEASES OF THE AORTA. 

more particularly so in the divisions, which contained 
a purulent matter. The pulmonary parenchyma was 
gorged with blood, but nevertheless crepitant. To- 
wards the union of the superior with the middle third 
of the left lung, on its external side, a tumour some- 
what hard presented itself, about the size of a pi- 
geon's egg, which seemed to us to have been formed 
by the blood effused into the texture of the organ. 
The pericardium contained about an ounce of serum, 
of a deep red colour. The heart was considerably 
larger than in the healthy state. This increased vo- 
lume depended upon the amplitude of the auricles, 
which were distended by a great deal of blood, more 
than half coagulated, mixed with some fibrous con- 
cretions, especially in the appendix of the left auri- 
cle, where this substance was dense and almost iden- 
tified with the fleshy columns. Each of the auricles 
was about double the natural size, without any change 
of thickness of their walls. 

The ventricles, but little developed, offered in 
other respects nothing peculiar. The valves of the 
left auriculo-ventricular orifice, the diameter of 
which was rather small, were thickened, and its 
fibrous zone was hard and nearly twice the natural 
thickness. At the top of the left ventricle, in the 
substance of the fleshy fibres, there was a concretion 
of calcarious phosphate, of a rounded form, and about 
the size of a small nut. 

The internal membrane of the aorta was red, espe- 
cially in the arch, and presented several small emi- 
nences, which we might regard as the rudiments of a 
cartilaginous degeneration. 

The stomach was healthy, and contained a small 



DISEASES OF THE AORTA. 177 

quantity of fluid matter. The mucous membrane, in 
several places, was of a beautiful red colour. 

The spleen adhered to the peritoneum by its con- 
vex surface; its texture was rather contracted. 

The liver was large, but healthy; its vesicle con- 
tained a brown-coloured bile, thick and agglutinated. 

Near the right ovary, in the thickness of the broad 
ligament, we found a cyst about the size of a pigeon's 
egg, filled with limpid serum. 

The pia mater was infiltrated with a considerable 
quantity of citrine coloured serum, especially at the 
superior part of the brain; the lateral ventricles con- 
tained about half an ounce of the same liquid. The 
plexus choroides, of a pale red, contained several small 
serous cysts. 

The brain itself was healthy, and its vessels ap- 
peared to contain but little blood. 



Case XL VIII. 

Ossification of the Mitral Valves, and Contraction of the Orifice 
to which they are attached. 

Marguerite Jolivale, porter, entered the hospital 
Cochin the 20th of March, 1810, affected, for ten 
months past, with great difficulty of respiration, 
which augmented on the least exercise. In addition 
to these symptoms were the following: inability of 
retaining the horizontal position; pulsations of the 
heart soft, but very extensive; pulse scarcely percep- 
tible on either side; sound flat throughout the whole 
inferior part of the chest; tension and manifest fluc- 
tuation of the abdomen; stools and urine seldom; lit- 



178 DISEASES OF THE AORTA. 

tie appetite; skin dry and cold; within three months, 
infiltration of the inferior extremities; emaciation. 

Debility increases daily; the patient spit blood, and 
died three days afterward, on the 27th of March. 

Inspection of the Body. — The heart is very volu- 
minous, and filled with blood; the mitral valves arc 
ossified, and the orifice which they circumscribe 
much contracted. The corresponding auricle is very 
thin, and twice the natural size. The two cavities 
of the chest contain a pint of clear serum; the peri- 
cardium contains about twelve ounces. The lungs, 
in other respects healthy, are swollen with a little 
blood. The abdomen contains two pints of serum; 
the mucous membrane of the stomach is red. The 
other viscera are healthy. 

Although this case has been so concisely described, 
we find in it all the most common symptoms of con- 
traction of the orifices of the heart; such as infiltra- 
tion, dyspnoea, smallness of the pulse and spitting of 
blood. 

The following cases will throw considerable light 
on the diagnosis of the disease, by offering to our ob- 
servation a symptom which was not known previous 
to the period when the method of mediate ausculta- 
tion was discovered by Laennee. 

Case XUX. 

Bellows Sound daring the Contraction of the Auricle; Palpita- 
tions, Dyspncea, Infiltration, fyc. Fibrocartilaginous Dege- 
neration of the Mitral Valve, and Contraction of the left Au- 
riculo-ventricular Orifice, 

Barbe LeJbant, aged sixty-three, washer-woman, 
large, and rather strongly constituted, having, how- 



DISEASES OF THE AORTA* 179 

fever* a narrow elongated chest, the sternum convex 
above and concave below, entered the hospital Co- 
chin the 4th of November, 1822, for a disease which 
she attributed to the fatigue of her occupation. She 
had vomited blood, she said, for more than five years. 
For three months, she had been troubled by the va^ 
rious symptoms which constitute aneurism of the 
heart, of authors. We observed, on attentive exa- 
mination, the following phenomena: cough, with 
sense of constriction in the middle of the chest; or- 
thopnea, threatening suffocation; face violet coloured; 
lips swollen; beatings of the jugular veins isochronous 
with those of the carotid arteries; palpitation; pulse 
irregular, unequal, intermittent, frequent and very 
small, although the pulsations of the heart were very 
strong* The pulsations of the ventricles were irregu- 
lar and intermittent; these intermissions, in general, 
are preceded by two quick contractions succeeding 
each other with a rapid but distinct impulse. The left 
ventricle contracts with a strong impulse and rather 
dear sound : the contractions of the auricles are ac- 
companied with a rushing sound analogous to the wind 
of a bellows, or, what is a better comparison, the mur* 
mur of the placental throb. The hand, applied on the 
precordial region, feels a vibratory movement, deep 
but well marked : it is suddenly and strongly raised 
by the motion of the ventricles: the lower extremities 
are infiltrated. 

Diagnosis.-— Contraction of the left auriculo-ven- 

tricular orifice; hypertrophy and dilatation of the left 

ventricle. (Prescription — Ptis. aperit. oxym. scillit. 

jul. tinct. digit. 

« The following days the patient gave herself up to 



180 DISEASES OF THE AORTA, 

the most discouraging feelings; her anxiety is ex- 
treme; the pulsations of the heart were sensibly di- 
minished; but oedema invaded the superior extremi- 
ties; the lips offered a pale violet tint; the patient 
could no longer enjoy a moment's sleep. The 15th 
of November, eleven days after entrance, although 
she did not appear worse than usual, she died suddenly 
after eating her broth. The file sound, indicated 
above, continued to the last. 

Inspection of the Body, twenty -four hours after 
death. — Lips and face of a livid violet colour; consi- 
derable infiltration of the limbs. 

Organs of Respiration and Circulation. — The 
heart is enormously distended with clots of blood, 
and three times as large as the fist of the subject. 
The coagula being removed, the organ itself is flab- 
by, and about one-third larger than natural. The 
left ventricle is dilated, its parietes hypertrophous, 
and seven or eight lines in thickness towards the 
base. The columns attached to the mitral valves are 
very strong. The right ventricle, thicker than in 
the natural state, is not sensibly dilated; the two au- 
ricles are dilated and thickened, but the left is one- 
third larger than the right; the texture of the heart 
is firm, and of a good colour. The mitral valve, en- 
tirely deformed, is hard, thick and fibro- cartilagi- 
nous; and the left auriculo- ventricular orifice is so 
contracted, that it will scarcely receive the end of 
the little finger; it forms an annular opening, the 
rounded lips of which are very resisting, and have a 
polished surface. The tricuspid valve is transformed 
into a kind of band, or collar, from two to four lines 
broad : one only of the processes of the valve is ob- 



DISEASES OF THE AORTA* 181 

servable; and this is converted into a small fibro-car- 
tilaginous tubercle. The right auriculo-ventricular 
orifice is uncommonly large, cannot be completely- 
closed by the valve. The aortic valves are thick- 
ened, without any sensible contraction of the orifice 
to which they are attached. That part of the peri- 
cardium which covers the heart offers a whitish 
pseudo-membranous patch, disseminated with miliary 
granulations, resembling venereal vegetations. The 
pleura is red and injected, and covered with a great 
many granulations analogous to the preceding. These 
albuminous agglomerated granules are more nume- 
rous on the pleura of the diaphragm, and are united 
with it in clusters. The left lung is quite crepitant; 
the right is distended with a sero-sanguine fluid; the 
mucous membrane of the bronchia is red. 

Abdominal Organs. — The cavity of the perito- 
neum contains a certain quantity of citrine coloured 
serum. The liver, swollen with blood, descends as 
far as the right iliac fossa; its vesicle contains ninety 
calculi of a cubic form^ unequal volume, and polished 
surface. The gastro-intestinal mucous membrane 
presents a red colour, which borders on violet and 
black in the stomach and greater part of the small 
intestine, and is bright and ruddy in the last convo- 
lutions of this intestine, as well as that of the colon. 

Encephalic Oi^gans. — The cavity of the arachnoid- 
contains a considerable quantity of serum. On the 
surface of the right lateral ventricle appears a very 
small patch of a yellow colour, with infiltration of 
blood: the rest of the cerebral substance is somewhat 
soft. The sinuses, the veins which ramify over the 
convexity of the hemispheres, and the internal jugu- 



182 DISEASES OF THE AORTA.- 

lar veins, are swollen with black blood : the latter arc? 
at least as large as the thumb. 

This patient presented, as it were, a combination of 
all the positive signs of hardening of the mitral valve^ 
and contraction of the orifice which it circumscribes. 
These are, first, the bellows, file or rasp sound; se- 
condly, the vibratory thrill, or purring tremor, ac* 
cording to M. Laennec, who has justly compared 
this tremor to the purring noise produced by cats 
when they are caressed; thirdly, the inequality, ir- 
regularity, intermittence and smallness of the pulse. 
It is indeed true, that the murmur of the left auricle 
was heard, not only in the region of the left cavities^ 
but also under the sternum. This fact seems contra- 
dictory to the proposition of M. Laennec, according 
to whom the pulsations of the left cavities are heard 
in the region of the cartilages of the fifth, sixth, and 
seventh ribs, and those of the right cavities under the 
inferior part of the sternum. But remark, that in the 
case which occupies us, the tricuspid valve itself was 
considerably altered, while its orifice, far from being 
contracted, w r as dilated; and, farthermorc, in conse- 
quence of its great size, the heart might be carried 
towards the right side. Lastly, this fact ought to be 
regarded, at present, only as an exception to the ge- 
neral rule proposed by M. Laennec, of which we have 
frequently had occasion to confirm the truth. The 
following cases will serve, in some measure, to favour 
this opinion. 



DISEASES OF THE AORTA. 183 



Case L. 

Bellows Sound, Inequality, and Irregularity of the Pulse, In- 
filtration, Dyspnoea, fyc. — Contraction of the Auriculo-ventri- 
cular Orifice, and Fibrocartilaginous State of the Mitral 
Valve, fyc. 

Marie Simon, aged forty-seven, seamstress, bru- 
nette, of a feeble and delicate constitution, having a 
very narrow chest and deformed vertebrae, entered 
the hospital Cochin the 21st of February, 1822. She 
had not been regular for five years; she had suffered 
long-continued domestic disappointment, and had 
made immoderate use of coffee. In 1813, she began 
to perceive that her face and hands were of a violet 
colour; that the lower extremities were swollen, and 
that she suffered, on the least exercise, palpitations 
and difficulty of breathing. The employment of ape- 
rients and diuretics dissipated the (Edematous swell- 
ing in six weeks: some palpitation was always felt. 
Nevertheless, her condition was supportable until 
the year 1817; but, at this period, the cough, return 
of suffocation, and spitting of blood, obliged her to en- 
ter the Hotel Dieu. M. Recamier had some leeches 
and a blister applied, &c. At the end of six weeks, 
she left the hospital somewhat recruited. Two months 
afterwards she entered the Cochin hospital; and at the 
end of three months' treatment, she went out in tole- 
rable health. The symptoms reappeared, neverthe- 
less, some time after, and have never been since en- 
tirely removed; only they augmented at intervals, 
and occurred in paroxysms. Ten days before her 
last entrance to the hospital Cochin, they had as- 



184 DISEASES OF THE AORTA. 

sumed an alarming intensity, and were complicated 
with pleuritic pain, and haemoptysis, allowing the 
patient no intervals of relief. Her complexion was 
livid, and of a leaden hue; her face expressed fright 
and anxiety; the subcutaneous veins were prominent; 
many spots of livid red were observed on various 
parts of the skin; the legs and hands were cold, and 
violet coloured; the pulse was small, precipitous, un- 
equal, irregular and intermittent, contrasting with 
the strong, dry, violent and tumultuous beatings of 
the heart : these produced an elevation of the left 
side of the chest, even as high as the clavicle; pain 
was felt in the right side; the sputa frothy, and 
slightly tinged with blood; the patient, threatened 
with suffocation on the least exertion, was, notwith- 
standing, in continual jactitation. 

Auscultation. — The pulsations of the heart resem- 
bled a kind of tic-tac, of unequal movement, and so 
precipitous, that it was very difficult to analyze them; 
those of the left ventricle imparted to the cylinder, 
a strong impulse, and were moderately sonorous. We 
heard, in the region of the left cavities, quite a loud 
murmur. Mucous rattle with large bubbles in the 
whole anterior part of the chest; kind of suspicious 
snoring in the right side; respiration loud on the 
back part, and pectoriloquy very strong in the region 
of the right scapula. 

Diagnosis. — Contraction of one of the orifices of 
the left heart, with hypertrophy; tubercles and pul- 
monary excavations. 

Prescription. — Ptisan aperit. Jul. diuret. et sed. 

The following days no relief; cough continual, with 
rapid, precipitous, but rather feeble paroxysms, agi- 



DISEASES OF THE AORTA. 185 

tation, giddiness, fainting, tendency to drowsiness, 
interrupted by anxiety at every moment; orthopncea, 
eyes prominent, dull and almost staring. Soon the 
patient had no longer sufficient strength to sit up; 
the trunk of the body was inclined to the right side, 
the head high and thrown backward, the mouth wide 
open: she seemed to stifle rather than respire: lastly, 
speech and respiration failed her; she uttered, how- 
ever, in a feeble voice, some incoherent words, said 
she felt she was dying, and, accordingly, expired 
the sixth day after entrance. 

Inspection of the Body, twenty-four Hours after Death. 

1. External Appearances. — The face and the 
hands have lost the livid blue tint; the violet spots, 
which exist in different parts of the body have dis- 
appeared; the vertebral column is deformed, the tho- 
racic portion inclining to the right, the abdominal 
portion to the left, represents an elongated S, the 
first curvature of which considerably diminishes the 
cavity of the chest. 

2. Organs of Respiration and Circulation. — Or- 
ganized adhesions, fibro-cartilaginous at the superior 
part of the chest, cellular throughout elsewhere, 
uniting the parietal and visceral folds of the pleura; 
at the left, the fibrocartilaginous false membrane is 
incrusted with large osseous plates; the left lung, 
about the size of a common spleen, choked up, as it 
were, by the surrounding organs, in the narrow ca- 
vity which it occupies, is red and yet crepitant, al- 
though it contains quite a large number of crude tu- 
bercles; the summit of the right lung, tuberculous 
throughout, is excavated by several caverns, one of 

24 



186 DISEASES OF THE AORTA, 

which is quite large: the remainder of this lung is 
crepitant and a little swollen. The heart and large 
veins are stuffed with liquid or coagulated blood; the 
former, twice as large as the fist of the subject, is 
thrust upward by the abdominal organs as far as the 
clavicle, and covers the whole interior left parietes 
of the chest/ and a portion of the right. The left 
ventricle is voluminous, especially considering the 
smallness of the subject; its walls, towards the base, 
are six to seven lines thick; its cavity is evidently in 
the natural state; the walls of the left auricle are 
thickened; the fleshy columns of its appendix are so 
large that they resemble those of the ventricles; on 
the internal surface of this auricle is seen a cartila- 
ginous plate, about the size of the nail; the left auri- 
culo-ventricular orifice is so contracted, that it re- 
sembles a fissure more than an opening; the contour 
of the thickened bicuspid valve forms a kind of ring, 
the resisting tissue of which appears white and fibro- 
cartilaginous, when cut, and grates under the knife. 
The right auricle and ventricle, distended by a large 
quantity of blood, are in other respects in the healthy 
state. The ventriculo-aortic orifice is contracted by 
the presence of three pisiform tubercles, fixed on 
the middle of the free edge of the sigmoid valves, 
which are nothing but the tubercles of Arantius, de- 
veloped, hardened, and fibro-cartilaginous, like the 
mitral valve. The internal membrane of the aorta is 
speckled with cartilaginous laminae. 

3, Abdominal Organs. — These viscera, of consi- 
derable volume, are, as it were, pushed into the ca- 
vity containing them; they are also protruded deeply 
into the chest, so as to usurp a portion of the space 



DISEASES OF THE AORTA. 187 

destined for the heart and the lungs. The mucous 
membrane of the stomach presents a deep marked red, 
which extending into the duodenum, the jejunum, and 
commencement of the ileon, loses its intensity in the 
remaining portion, then sinks into the ccecum, and is 
found throughout the large intestine. The internal 
membrane of the bladder, distended by a great quan- 
tity of urine, is both red and injected. 

Encephalic Organs. — The arachnoid contains a 
certain quantity of serum; the meninges are injected; 
the plexus choroides contains within its substance a 
series of small diaphanous hydatidiform vesicles, about 
the size of hemp-seed. 

It is impossible to imagine more horrible dyspnoea 
than that which afflicted the patient in the present 
instance. This may easily be conceived. In fact 
how numerous were the obstacles both to circulation 
and respiration ! an extremely narrow chest, a part 
of which was compressed by the abdominal viscera; 
a tubercular affection of the lungs, which necessarily 
diminished the extent of the respiratory surface; a 
contraction ef the left auriculo-ventricular orifice, 
which concurred to the same effect, by preventing 
the free passage of the blood to the ventricle, and 
consequently producing a distention of the pulmo- 
nary vessels, the right cavities, and the whole venous 
system ! lastly, the volume of the heart itself in con- 
nexion with the preceding causes. 



188 DISEASES OF THE AORTA. 



Case LI. 

Bellows Sound; St?*ong 9 Concentrated and Heavy Contractions of 
the Left Ventricle — Contraction of the Left Auricido- Ventri- 
cular Orifice — Hypertrophy of the Left Auricle and Ve?i- 
tricle, SfC. 

Eleonore Lemindre, aged 34, tailoress, of a san- 
guine lymphatic temperament, having suffered great 
depression of spirits, experienced, in the course of 
1820, symptoms of what is called disease of the heart. 
In 1821, after a paroxysm of cough, she spit blood; 
menstruation had disappeared within two months; 
oppression, and considerable palpitation occurred on 
the least exercise, when she entered the Cochin hos- 
pital on the 7th of February, 1822. Her face was 
bloated, without being either violet or livid; the 
skin was cold, the abdominal limbs infiltrated; the 
patient suffered pain in the chest, especially in 
the precordial region; she respired sitting rather 
than lying in the bed, coughed frequently and ex- 
pectorated a sero-mucous matter, mixed with streaks 
of blood. 

Auscultation. — The cylinder applied over the left 
ventricular region, a very remarkable murmur is 
heard, analogous to the sound of a bellows; it is 
thrown upward by the contractions of this ventricle, 
which are dull, concentrated and strong, whilst the 
pulse is very small, but hard. The bellows sound 
precedes the ventricular pulsations. In the region 
corresponding to the right cavities, nothing particu- 
lar is observed. Respiration natural throughout, ex- 
cept at the top of the right lung, where is heard a 



DISEASES OF THE AORTA. 189 

dry, sonorous rale, interrupted by prolonged suspi- 
cious sounds. 

Diagnosis. — Contraction of the left ventricular 
orifice, with hypertrophy of the corresponding ven- 
tricle; catarrh at the superior part of the right lung. 
(Julep; digital; aperit. oxymel scillit.) Five days 
after entrance, pleuritic pain supervened, which was 
removed by the application of twenty leeches. Re- 
pose, seconded by the measures above noticed, tran- 
quillized the palpitations, and diswsipated almost com- 
pletely the cedema, when, on the 23d of February, 
after having eaten aliments, brought her by her pa- 
rents, the patient was seized with a violent shivering 
and vomited several times. The 24th, erysipelas of 
the face, red tongue, thirst, hot skin, pulse frequent. 
(Diet, sweetened gum-water.) 25th and 26th, the 
erysipelas extends towards the neck and scalp; the 
eyes are completely closed by the swollen lids. 27th. 
The erysipelas continues to spread, acute pain in the 
throat, respiration embarrassed, short and precipi- 
tous. (The patient refuses, with obstinacy, the 
leeches.) 28th. Very considerable inflammatory swell- 
ing of the anterior region of the neck seems to stran- 
gle the patient: speech and deglutition very difficult, 
alternations of agitation and stupor. The patient 
having no longer the strength to cough or spit, thrusts 
her fingers continually into her throat, as if to remove 
the impediment to the free passage of the air. The 
next day, 1st of March, increased strangulation, enor- 
mous tumefaction of the neck, impending suffocation, 
with almost complete aphonia, determined the pa- 
tient to consent to the application of leeches; but it 
was too late; nevertheless, thirty were applied; two 



190 DISEASES OF THE AORTA. 

hours afterward the patient died in a state of as- 
phyxia. 

Inspection of the Body twenty-four hours after death. 

A good degree of flesh still remaining, infiltration 
of the lower extremities. The lungs throughout are 
quite crepitant, and but little swollen. The mucous 
membrane of the bronchia and larynx is red and in- 
flamed; the epiglottis and its ligaments are consider- 
ably thickened; the glottis presents a narrow open- 
ing, occasioned both by the inflammatory swelling, 
and the mucous secretions collected round its margin. 
The cellular tissue of the larynx, that of the face, es- 
pecially the lids, is swollen, injected, and infiltrated 
with pus. The pericardium contains about half a 
glass of lemon-coloured serum; the heart is much en- 
larged, is filled with clots of blood; the walls of the 
left verftricle are full an inch thick; its capacity is 
sensibly diminished; the left auricle is dilated and hy- 
pertrophied; the left auriculo-ventricular orifice is 
reduced to a kind of ovular chink, the greatest dia- 
meter of which is not more than three lines. The 
mitral valve, deformed, and folded over, forms a kind 
of ring or elliptical collar, the dense, resisting, fibro- 
cartilaginous texture of which creaks under the divi- 
sion of the scalpel. The right ventricle is nearly in 
its natural state; the corresponding auricle is mode- 
rately dilated; the valves of the ventriculo pulmonary 
orifice are red, covered with small vegetations, and 
strewed with cartilaginous points; the tricuspid valve 
is equally red, thick, folded on itself and deformed, 
but without contraction of the orifice to which it is 
annexed. The peritoneum contains about a pint of 



DISEASES OF THE AORTA. 191 

diaphanous citrine coloured serum. The mucous 
membrane of the stomach presents, especially in the 
pyloric region, a red colour which is prolonged into 
the duodenum, the jejunum, and the ileon, where it 
gradually terminates. 

The large intestine is contracted and healthy; and 
so is the bladder. The cavity of the uterus contains 
a little blood. 

We shall not multiply farther the cases of indura- 
tion of the mitral valves, and of contraction of the 
corresponding orifice : those which we have read are 
sufficient to make known the principal anatomical 
characters of the disease, and demonstrate, sufficient- 
ly, that if the diagnosis of these organic lesions, pre- 
sented formerly insurmountable difficulties, it has 
become of great simplicity in the present day, as, 
fortunately, we possess a mode of exploration, which 
furnish us signs easy to discriminate. We shall re- 
turn, hereafter, to the subject of diagnosis, and bring 
together, with care, and in a single view, all the data 
on which it may be established. We shall proceed, 
in the meantime, to relate a few cases, respecting; 
induration of the aortic valves. 



II— INDURATION OF THE SIGMOID VALVES OF THE 

AORTA. 

Case LII. 

Cartilaginous State of the Valves of the Aorta — Aneurism with 
Alteration of the Internal Membrane. 

Boulenoy, aged 66, teacher, of a good constitution^ 



192 DISEASES OP THE AORTA. 

entered the hospital the 2nd of September, 1810, 
complaining, for fifteen years, of pulsations in the an- 
terior and superior part of the sternum and dyspnoea, 
augmented by walking and exercise. For three 
months past, a tumour had begun to show itself in the 
situation of these pulsations; at the time of entering 
it was about the size of a pigeon's egg, and presented 
evident pulsations. The patient very meagre; the 
legs were (Edematous, and he could only respire in 
the vertical posture. 

He died two hours after his arrival. 

Inspection of the Body. — The curvature of the 
aorta was much dilated, and formed a considerable 
tumour, which compressed the trachea : the anterior 
portion of this tumour, presented a large opening, 
resulting from the rupture of the three arterial coats : 
its cavity was filled with fibrine. The internal coat of 
the artery was ragged, and strewed with osseous par- 
ticles: the descending thoracic aorta, offered the 
same lesions. The first and the second left ribs, and 
a great part of the sternum were eroded. 

The aortic valves were cartilaginous. 

An ulcer, with unequal edges, occupied the whole 
thickness of the posterior and lateral left part of the 
trachea, one of the rings of which was diseased. The 
internal membrane was red and covered with mucus. 

The right lung was filled with blood, and its infe- 
rior portion was crowded with suppurating miliary 
tubercles. 

The induration of the valves, in this case, had not 
yet arrived to the cartilaginous consistence : we shall 
find it more advanced in the following, and of an os- 
siform nature. 



DISEASES OF THE AORTA. 193 

Case LIIL 

Ossification of the Aortic Valves. 

Marie-Charlotte, aged 53, working-woman, strong- 
ly constituted, had not menstruated since her 38th 
year. For seven years past, she had experienced 
great difficulty of respiration, augmented by walking 
and other exercises. Two months before she entered 
the Cochin hospital, which took place on the 28th 
of June, 1809, she was affected about the region of 
the heart with violent, tumultuous, and embarrassed 
pulsations; frequently started from sleep; the pulse 
became insensible in both wrists, a sensation of em- 
barrassment about the attachments of the diaphragm; 
the chest returned a flat sound; the inferior extremi- 
ties were infiltrated, the abdomen fluctuating, and 
the horizontal position was impossible. These symp- 
toms augmented every day, the superior extremities 
became infiltrated, the whole constitution became 
cold, pulsations were perceived in the jugular veins; 
the lips were slightly injected, the face bloated, pale, 
and expressive of fatigue; the dyspnoea such, espe- 
cially in the evening and night, that the patient is 
obliged to leave her bed, and remain in an arm chair; 
she spit blood for three days; lastly, insomnia is con- 
tinual, infiltration enormous, notwithstanding the use 
of aperients; the anxiety became extreme, and the pa- 
tient sunk, after an agony of short duration, on the 
26th of July. 

Inspection of the Body. — The heart is much more 
voluminous than in the natural state. The walls of 
the left ventricle are about one-third thicker than in 

25 



194 DISEASES OF THE AORTA, 

the healthy state. The three aortic valves are ossi- 
fied; the right valve, especially, which presents an 
ossification about the size of a pigeon's egg, con- 
tracting the ventriculo-aortic orifice, to such a de- 
gree that the little finger cannot be passed into it. 

The lungs are healthy. The right cavity of the 
chest contains about a pint of serum, and the left 
about half a pint. 

The pericardium much distended, contains twenty 
ounces of a similar fluid, a little turbid. 

You will perceive, in this case, an example of os- 
seous concretion so considerable, that few similar ones 
are to be found. The symptoms which accompanied 
the disease, are absolutely the same as in the pre- 
ceding cases, dyspnoea, infiltration, anxiety, beating 
of the jugular veins, &c. 



HI— INDURATION OF THE TRICUSPID VALVE AND THOSE 
OF THE PULMONARY ARTERY. 

Case LIV. 

Cartilaginous State of the Tricuspid and Bicuspid Valves, -with 
Contraction of the Orifices to which they are attached. 

Germaine Mesnier, aged 30, had enjoyed^ in her 
infancy, pretty good health, excepting that she had 
always had a short breath. Having menstruated at 
seventeen years of age, she had begun, two years 
previously, to be affected with palpitation. The 
pulsations of the heart increased on the approach of 
the menstrual period, diminished when the flow took 



DISEASES OF THE AORTA. 195 

place, and retained their violence when it failed. 
Moral affections and the least exercise, excited the 
palpitations: at the age of twenty-eight years, they 
became habitually more violent. When their inten- 
sity became extreme, this patient provoked nausea 
and vomiting, by introducing the fingers into the 
mouth, and felt herself relieved afterwards. Before 
having imagined this method, her sufferings were 
prolonged often during the whole day, or, at least, 
she could not obtain relief until the distress and anx- 
iety increased to such a degree as to induce sponta- 
neous vomiting. 

Such was the state of this woman, when she en- 
tered the hospital Cochin, the 20th of September, 
1814. From this period until the 25th of January, 
following, antispasmodics, digitalis purpurea, in its 
different forms, were used; leeches were applied to 
the anus, and bleeding was practised in the arm, 
which procured only momentary melioration. The 
palpitations, without being stronger, soon became 
more frequent; the cough became habitual, and the 
infiltration of the legs, which had disappeared soon 
after entrance by the use of the preparation of squill, 
was renewed. On the 10th of February, all the symp- 
toms had become more intense. The respiration was 
much more embarrassed, and even wheezing; violent 
palpitations were observed in the whole anterior left 
region of the thorax : they became insupportable when 
the head was a little depressed, so that the patient was 
obliged to remain constantly sitting in her bed. The 
face, which, until then, had been in a state nearly natu- 
ral, became pale and bloated. The chest resounded 
quite well behind, toward the left; it gave a flat sound at 



196 DISEASES OF THE AORTA. 

the anterior and right portion; a little obscure in the 
region of the heart. The pulsations of the heart, 
which the ear, applied to the chest, could hear very 
distinctly, were redoubled every night, and, during 
this kind of regular paroxysm, they were so violent 
as to heave up the bed-clothes, and could even be 
heard at some distance. 

The pulse was, ordinarily, frequent, small, very 
irregular, and without harmony with the pulsations 
of the heart. 

Soon, at every step that the patient attempted, 
she suffered such oppressed respiration that she was 
in immediate fear of death. The abdomen became 
voluminous, hard and fluctuating; the urine was thick- 
ened, red and small in quantity. Sudden startings 
frequently disturbed her sleep. 

1st March. Constant oppression, respiration short, 
precipitous; pulsations of the heart unequal, variable, 
generally sufficiently strong; pulse small, feeble, al- 
most insensible; a veinous red and illuminated expres- 
sion of countenance; infiltration enormous; suppres- 
sion of urine. 

Lastly, this unfortunate woman is obliged to re- 
main, night and day, in an arm chair, tormented by 
insupportable anguish, with which she died on the 
25th of March, 1815. 

Inspection of the Body. — The two cavities of the 
pleura are full of citrine coloured fluid, and the peri- 
cardium contains about 16 ounces of a similar liquid. 
The heart is much more voluminous than in the na- 
tural state; the portion of the serous membrane which 
covers the right auricle offers here and there some 
points of erosion. This auricle, at its inferior part. 



pi 

DISEASES OF THE AORTA. 197 



is three times larger than in its natural state; its tex- 
ture presents a considerable thickening, the true 
muscular hypertrophy. The fibres are so much en- 
larged as to form bundles, similar to the ventricular 
columnse. The tricuspid valves are hard, thickened, 
united together by their edges, and form a kind of 
cartilaginous septum, pierced in the middle by a 
hole, which will scarcely admit the little finger. 
The right auricle does not present any marked pe- 
culiarity. The valves of the pulmonary artery, also, 
offer nothing remarkable. The left auriculo- ventri- 
cular orifice has become considerably contracted; its 
valves form a very projecting border, the sides of 
which are approximated, and almost contiguous; al- 
lowing only a small opening between them, or rather 
a kind of transverse slit. This border, the projec- 
tion of which corresponds to the right auricle, is, in 
some points of its extent, about four lines thick; its 
texture, of a fibrocartilaginous nature, offers diffe- 
rent points of ossification. The fibro-cartilaginous 
formation has affected only about half of the valve; 
and while there was scarcely any motion of this part, 
the base appeared as flexible as in the natural state. 
The left ventricle retained its natural capacity, but 
its walls were evidently hypertrophied : they were 
more than an inch thick in the greater part of their 
extent. The caliber of the aorta was contracted; its 
valves were thickened, hard, cartilaginous, inflexi- 
ble, and formed by their reciprocal union a kind of 
irregular ring, the diameter of which was about three 
lines. 

This case presents us with a remarkable, and hap- 
pily a rare example, of almost all kinds of induration, 



198 DISEASES OF THE AORTA. 

affecting at the same time the tricuspid, mitral and 
aortic valves, and of contraction of almost all the ori- 
fices of the heart. 

But we would call the attention particularly to the 
subject of induration of the tricuspid vaJve. For 
twenty years we have not collected more than four 
cases of such hardening. We have cited the pre- 
ceding as the most interesting. We have never ob- 
served this induration, excepting in the cartilaginous 
state. We have never had an opportunity of seeing 
these concretions of calcarious phosphate, those ossi- 
fications we have so frequently spoken of, in the left 
heart. The pulmonary artery has never presented 
us with any change of this kind. Bichat also says, 
that he has never seen it in the right heart : he was, 
however, wrong to conclude from this that it could 
not exist. Corvisart has opposed this too general 
conclusion, both by reason and fact. Vieusens, Se- 
nac, Morgagni, Hunauld, and Joseph-Exupere Ber- 
tin, relate some examples of it, which we might add 
to those observed by ourselves. Most of the authors 
we have noticed, also, only mention facts of cartila- 
ginous hardening. 

We find a case of true ossification of the tricuspid 
valve, in the Journal de Medecine, by Corvisart, 
MM. Leroux and Boyer, vol. XIX. p. 468. 

Case LV. 

General William Whipple was affected, for a long 
time, with many symptoms of disease of the heart; 
such as palpitation on the least exercise, great anxi- 
ety, continual coldness of the extremities. The fa- 



DISEASES OF THE AORTA. 199 

tigues he experienced during the American revolu- 
tion aggravated his disease, and he died. 

Upon examination, the right auricle was found di- 
lated. The tricuspid valve was ossified, and closed 
the right auriculo-ventricular orifice, and was perfo- 
rated at its free edge with two holes, united by a fis- 
sure about an inch long, and nearly a line broad, and 
at its base with a third hole, which bordered the left 
ventricle on the mitral valve. The left cavities of 
the heart were in the natural state. 

If the induration of the tricuspid valves, and the 
contraction of the right auriculo-ventricular orifice 
are rare, the same alterations are still more so in the 
sigmoid valves of the pulmonary artery and its ori- 
fice. Here, however, are three examples; the first 
of which belongs to ourselves, while of the two others, 
one was recorded by M* Louis at the hospital of La 
Charite, and the other may be found in the seven- 
teenth letter of Morgagni. We shall only give an 
extract from the two first cases, which we shall have 
occasion to mention elsewhere. 

Case LVI. 

A woman fifty-seven years of age had been affect- 
ed from early childhood with extreme difficulty of 
breathing on the least exercise, and a violet red co- 
lour of the face. Afterward she experienced very 
strong palpitations, and frequent nasal haemorrhage. 
She died at the hospital Cochin of an inflammation of 
the brain, the paroxysms of which were marked by 
an augmentation of the beatings of the heart, brillian- 
cy of the eyes, and a rose colour of the lips. The 



200 DISEASES OF THE AORTA. 

ventricular contractions were accompanied with a 
tremor sensible to the hand, applied to the precor- 
dial region, and a rushing sound which was confirmed 
by immediate auscultation. At the opening of the 
body, we found the foramen ovale still open — the 
right cavities extraordinarily hypertrophied, and the 
orifice of the pulmonary artery closed, by a horizon- 
tal septum, pierced with a hole, of two lines and a 
half in diameter, beyond which the artery presented 
nothing remarkable. 

In this case, which is, perhaps, the only one of 
this kind known, if it is not very analogous to that of 
Morgagni, which we shall give below, the contrac- 
tion of the orifice of the pulmonary artery is not the 
result of an induration of the valves, but appears to 
be, in fact, an original vice of conformation. We 
thought we ought, however, to consider it in this 
connexion, since it is always a disease of the pulmo- 
nary orifice, and, furthermore, offers us an opportu- 
nity to confirm the existence of two symptoms which 
we consider to be of very great importance; namely, 
the vibratory tremor and thrill, which we have re- 
garded as the infallible signs of contraction of one of 
the orifices of the heart. 

Case LVII. 

A mason aged twenty-five years was received at 
the hospital of La Charite on the 5th of August, 
1823. He presented all the symptoms of a great 
obstacle to circulation and respiration. We heard, 
in the whole anterior part of the chest, a bellows 
sound, which was stronger in proportion to its near- 
ness to the sternum. Digitalis, bleeding, &c, were 



DISEASES OF THE AORTA- 201 

in vain employed; the patient died on the 20th day- 
after he entered. At the opening of the body, we 
found the right cavities nearly in the same state as 
in the preceding patient, that is to say enormously 
hypertrophied. One of the fleshy columns of the 
right ventricle lay over the orifice of the pulmonary 
artery, which it concurred to contract: this orifice 
Was, in fact, considerably contracted by the alteration 
of the sigmoid valves, which form a kind of fibrous 
rim, the opening of which was about two lines and 
a half in diameter. The tricuspid valves, yellow, and 
thickened at their adherent border especially, offered 
in this latter portion a partial ossification, of about a 
line in thickness. The left cavities exhibited nothing 
extraordinary.* 

The contraction of the pulmonary orifice, in this 
case, presents a great analogy with what is observed 
much more frequently in the aortal orifice; it has 
been accompanied with the bellows sound, a perfect- 
ly constant and characteristic symptom, as we are 
pleased to repeat. Lastly, in this case you will ob- 
serve a new proof of the possibility of ossification of 
the veinous valves, since the base of the tricuspid 
valve is in fact partially ossified. Here is the fact 
recorded by Morgagni. 

Case LVIII. 

A young woman, who had not left her bed from 
infancy, having the skin livid, and respiration much 

* At the commencement of the auricle, towards the pulmonary artery, was 
a hole of two lines in diameter, bordering the sigmoid valves of the aorta, 
and establishing a communication between that artery and the right ven- 
tricle. 

26 



202 DISEASES OF THE AORTA/ 

embarrassed, died at the age of sixteen. The right 
ventricle was hypertrophied, but enlarged, whilst, in 
the two preceding cases, it was reduced to the small- 
est dimensions; the right auricle was twice as large 
as the left, and thicker. The foramen ovale re- 
mained entire, and would admit the little finger. 
The pulmonary sigmoid valves were cartilaginous, 
and so intimately connected at their free edge, that 
they scarcely left an aperture so large as a lentil, for 
the passage of the blood. 



IV.— VEGETATIONS OF THE VALVES OF THE HEART. 

Case LIX. 

Thickening and Vegetations of the Aortic Valves. 

Louis Nicholas Menage, aged twenty-seven, tiler, 
firmly constituted, entered the hospital Cochin on 
the 24th of April, 1810. He was put in the surgi- 
cal wards, and presented the following state : bitter- 
ness of the mouth, anorexia, urgent thirst, epigastric 
pain, abdomen loose, little sleep. Three days after 
entrance, an emetic produced many ejections. The 
same day the patient suffered much from weakness, 
oppression, and colic pains. Some days after, he took 
two medicines which fatigued him much : the abdo- 
men became painful and tumid, as well as the legs, 
the thighs and the genital organs. We then trans- 
ferred the patient to the medical wards. Respira- 
tion was much embarrassed, the face swollen, the 
pulsations of the heart were quick and tumultuous, 
but the oedema of the arms prevented us from feeling 



DISEASES OF THE AORTA. 203 

the pulse very distinctly. Aperients were in vain 
employed; the strength diminished more and more, 
and the patient, after a long agony, died on the 23d 
of May, following.* 

Inspection of the Body. — The heart adhered very 
strongly to the pericardium; the walls of the left ven- 
tricle were very much thickened and dilated. The 
aortic valves were much thickened, and surrounded 
with little vegetations: one of them was perforated. 

You observe in this case, although many of the de- 
tails are wanting, the usual symptoms of obstructions 
to the circulation. The pulse is very difficult to be 
perceived : the pulsations of the heart are, notwith- 
standing, quick and tumultuous. The face is swollen, 
the abdomen fluctuating and tender, the limbs are 
infiltrated. The explanation of these phenomena is 
easily given : the blood, retained in the cavities of 
the heart, which it distends, excites palpitations; and 
its accumulation in the lungs and the venous system, 
determines dyspnoea, ascites and oedema of the ex- 
tremities. 

Case LX. 

Vegetations on the Aortic Valves. 

Marie Rose Genet, aged sixteen, cotton factory 
girl, left the Hotel Dieu and entered the Cochin hos- 
pital on the 3d of January, 1813. Her respiration 
was much embarrassed; she felt acute pain in the left 
side, and hypochondrium; she coughed frequently; 
the pulse was frequent, small, and regular; the beats 

* This person gave no other information respecting his previous state, 
than that he had been bled twelve times, at the Hotel Dieu, for a swelling. 



204 DISEASES OF THE AORTA. 

of the heart were quick and precipitous; the legs, 
the thighs, and the abdomen were oedematous : she 
could not sleep an instant. 

We could not obtain any information respecting 
her previous state of health; we learnt, only, that she 
had not menstruated. 

She died some hours after entrance. 

Inspection of the Body. — The pericardium was 
covered by false membrane, much thickened. The 
capacity of the left ventricle was three times as great 
as natural, without any appreciable thickening of its 
parietes. The free edge of the aortic valves presented 
small projecting vegetations on the side towards the 
ventricle. 

Case LXL 

Ossified Vegetations on the Aoital Valves. 

Claude Roger, aged fifty-five, quarry-man, had 
suffered, for six years, a considerable difficulty of 
respiration, which was relieved by various modes of 
treatment without being entirely removed. Never- 
theless, the face has become pale and bloated, the in- 
ferior extremities are swollen, suffocation seems im- 
pending on the least motion, cough is frequent and 
followed by an expectoration tinged with blood; the 
pulse is small and frequent, the sleep troubled by 
starting. In this state the patient was received into 
the hospital Cochin. The symptoms soon became 
aggravated; the jugulars presented evident beating, 
the chest gave a flat sound in the whole of its extent, 
infiltration was increasing; and death took place on 



DISEASES OF THE AORTA. 205 

the 15th of February, 1807, thirty days after he en- 
tered the hospital. 

Inspection of the Body. — The abdominal viscera 
appeared healthy; the heart retained nearly its natu- 
ral volume, the left ventricle, only, is a little dilated; 
the valves of the aorta are ossified; one of them pre- 
sents well marked vegetations. 

Case LXII. 

Vegetations on the Aortic Valves. 

Deschamp, aged forty-four, day labourer, of a lym- 
phatic temperament, having from infancy a short res- 
piration, living for three years in a damp district, 
having never had any other disease than a quartan 
fever, was admitted, on the 4th of November, 1810, 
to the hospital Cochin, for a pain, with oedema of the 
left foot. This disorder being dissipated promptly, 
and as it were spontaneously, he left the hospital a 
few days afterwards; but returned on the 25th of 
December of the same year, affected with continued 
fever, cough, mucous expectoration, pain in the an- 
terior part of the chest; pulse frequent, soft; cepha- 
lalgia, and depression. 

We prescribed blood-letting to the extent of xii?, 
and a pectoral julep. 

The symptoms continuing, the patient was again 
questioned respecting his previous state. He ob- 
served that his habitual dyspnoea had augmented 
within five years, and that he had been subject, from 
time to time, to palpitations. About the 15th of Ja- 
nuary following, respiration had become shorter, in- 
terrupted by a kind of rushing murmur under the 



206 DISEASES OF THE AORTA* 

sternum; obscure and tumultuous palpitations, coin- 
ciding with a frequent and hard pulse. The pa- 
tient coughed, expectorated a viscous matter, and 
had almost perpetual sweating of the chest and fore- 
head. He laid habitually on the back, decubitus be- 
ing impossible on the right side, whilst he could lie on 
the left. The repose was interrupted by starting in 
the sleep, or troubled by dreams, in which the pa- 
tient thought he saw water fall upon him, and felt, 
he said, as if the heart were drowned. The sound 
was a little flat towards the precordial region : dysp- 
noea and oppression augmented during the humid 
paroxysms : the left leg was (Edematous and painful. 

The 25th of February, the patient vomited dark- 
coloured matters, was prostrated with extreme weak- 
ness, and died the same month. 

Inspection of the Body. — The inferior lobe of the 
right lung was hepatized; the pleura thickened, soft 
and red; the corresponding cavity was filled with li- 
quid slightly tinged with blood. The left lung was 
healthy. 

The volume of the heart was double its natural 
size; the left auricles and ventricles were enormous- 
ly dilated, with very considerable thickening of their 
parietes. 

The free edge of the aortic valves was covered 
with soft and whitish vegetations, having the ap- 
pearance of cauliflowers. The origin of the aorta 
was covered with similar excrescences. 

The right ventricle and corresponding auricle pre- 
sented nothing extraordinary. 



DISEASES OF THE AORTA. 207 

Case LXIIL 

Vegetations on the Aortic and Mitral Valves. — Hypertrophia of 
the Left Ventricle. 

Victor-Etienne Cordier, aged twenty-four, lock- 
smith, of habitually infirm health, subject to frequent 
headachs and nasal hemorrhages, which procured 
him great relief, having had one in the course of the 
year 1809 so profuse that he fainted several times, 
was attacked, a short time after, with an intermittent 
tertian fever, which continued four months. Being 
obliged, afterwards, to take the trade of a water car- 
rier, he soon felt, and for the first time, very acute 
pulsations whenever he went up a high pair of stairs. 
These palpitations became more atid more violent; 
he abandoned his new employment to assume what 
he thought preferable- 1 — that of a carman. Having 
been one day suddenly exposed to cold when covered 
with perspiration, he soon experienced, in the right 
side of the chest, a sharp pain, which induced him 
to go to the hospital Cochin, in the month of January, 
1812. The pungent pain, , dyspnoea, cephalalgia, 
redness of the face, pulsations of the heart, strong 
and rapid, the pulse full and vibrating, induced M. 
Peyrade, then attached to that hospital, to practise 
blood-letting in the arm. It was followed with marked 
relief. On the morrow, at the visit, we applied 
twelve leeches to the anus. This new bleeding, also, 
had a very advantageous result. 

At the end of fifteen days, the patient left the hos- 
pital with all the appearances of a perfect cure; but 
he returned the 7th of April following, presenting 
the symptoms which follow: — violent headach, with 



20S DISEASES OF THE AORTA. 

sense of pulsation, redness of the face, beating of the 
temporal arteries, dimness of vision, frequent nasal 
hemorrhagia; cough, with mucous sputa somewhat 
thickened; pulsations of the heart violent, rapid, su- 
perficial; pulse vibrating and regular; suffocation on 
the least exercise; oppression; flat sound in the re- 
gion of the heart; startings in the sleep. 

Bleeding in the arm produced a relief of short du- 
ration. We did not repeat it, because the nasal he- 
morrhages, which returned almost every day, ap- 
peared to supply with advantage every other mode 
of evacuation, and were constantly followed by me- 
lioration of the symptoms. 

About the 15th of May, the strength diminished 
considerably, the face became pale, livid and swollen; 
the lips lost their vermilion colour, which they had 
until then retained; the head felt heavy; sleep was 
interrupted by fanciful dreams, starting from bed, 
violent shocks, and oppression of breath. The legs 
began to infiltrate, and the infiltration soon became 
general. The patient could no longer pass his nights, 
except by sitting up in bed; the urine became small 
in quantity, and thick. The preparations of squills, 
employed in various forms, produced no salutary 
effect. 

About the beginning of the month of June, the 
slightest distention of the stomach produced suffoca- 
tion. The patient, who was naturally sad, became 
more and more sombre and disquieted, and he called 
for death as the only termination of his sufferings. 
About the 15th of the same month, new nasal hemor- 
rhages very abundant supervened, and momentarily 
calmed the suffocation and violence of the pulsations 



DISEASES OF THE AORTA* 209 

Of the heart, but much augmented the debility. Ne- 
vertheless, the dyspnoea became continual, the dull 
beating of the heart produced merely a kind of for- 
mication, the pulse became insensible, infiltration in- 
creased, the urine was less in quantity, the patient 
is reduced to pass his nights constantly sitting on a 
chair, the head and the right side supported on his 
bed, overpowered by stupor, which the difficulty of 
respiration interrupted at every moment. He died 
about the 25th of June, of the same year. 

Inspection of the Body. — Both lungs adhered, at 
several points, to the parietal pleura; both cavities of 
the chest contained some ounces of serum; a gelati- 
nous matter, in considerable quantity, covered seve- 
ral portions of the external surface of the lungs, which 
in other respects were healthy. 

The pericardium contained eight ounces of limpid 
serum. The walls of the left ventricle were about 
fifteen lines thick at the base : this thickness gradual- 
ly diminished towards the point of the heart, where 
it was also quite apparent. Numerous very irregular 
ramifications were implanted on the sigmoid valves, 
contracting considerably the orifice of the aorta: 
smaller vegetations, about the size of millet seed, 
projected from the tendinous cords of the mitral 
valves.* The rest of the heart offered nothing pe- 
culiar. 

This case affords a new proof of the influence which 
acute diseases of the lungs have upon those of the 

* This patient was frequently asked if he had ever been affected with ve- 
nereal diseases, and constantly replied in the negative; and, farthermore, did 
not present any trace of it. He had only experienced, at the age of sixteen 
rheumatic pains, for which he had taken several baths at the Hotel Dieu. 

27 



210 DISEASES OF THE AORTA* 

heart. And although the pleuro-pneumonia appear^ 
to have undergone a favourable termination, the ven- 
tricular hypertrophy, which was manifested by the 
most evident signs, soon presented the most positive 
and unequivocal signs of it. At the same time, the 
symptoms of cephalic congestion appeared; the epis- 
taxis was renewed with great violence, and propor- 
tioned, no doubt, to the augmentation of the hyper- 
trophy of the left ventricle : the quick and violent 
beatings of the heart, the vibrating and strong pulse, 
all the principal signs which have been regarded as 
those belonging to a kind of aneurism, were mani- 
fested, although there did not exist any aneurism; 
that is to say, dilatation of any cavity of the heart. 
Nevertheless, these symptoms became, by degrees, 
less and less sensible; and another series of phenome- 
na supervened, which has been wrongly attributed 
to an aneurism in a certain stage of development. 
These symptoms are those of an obstacle to the course 
of the blood, which, in the present case, were found 
principally about the ventriculo-aortic orifice; which, 
in consequence of its contraction, was opposed to the 
free passage of the blood, and compelled it to flow 
back towards the pulmonary system: add to this, that 
in consequence of the immobility of the valves, the 
blood, propelled through the aortic tube, might af- 
terwards enter in part into the ventricle, when this 
artery Came to react on the column of blood. 



*$ 



DISEASES OF THE AORTA. 211 



Case LXIII. 



Fungoid Vegetations of the Valves of the Aorta, with Cartilagi- 
nous Points. 

Cordelier, aged fifty-six, day labourer, had never 
previously a serious disease, when he was attacked, 
in the month of February, 1811, with a cold, with at 
first viscous expectoration, then more thick, opaque 
and white. It was in this state that the patient de- 
cided to enter the hospital Cochin, the 6th of May 
following. Respiration was difficult, the pulsations 
of the heart were obscure, but regular; the pulse 
sufficiently developed and a little hard; the chest did 
not give a very clear sound, especially at the left; 
the feet were (Edematous; slept but little; skin gene- 
rally warm, without sweat; habitual constipation. 
(Infus. hys. mel. jul. Kermes, grs. ij. oxymel scillae, 
acetat. potassse.) 

Nevertheless, all the symptoms augmented pro- 
gressively. 17th of May, the patient experienced la- 
borious breathing, attended with expectoration, dif- 
ficult and mixed with blood; the pulse strong, and 
prompt. Free blood-letting from the arm does not 
diminish the disorder. 19th of May, difficulty of 
breathing more frequent, the sputa suppressed; the 
patient can rest only in the sitting posture. He died 
in the evening. 

Inspection of the Body. — The right lung was he- 
patized, and the corresponding thoracic cavity con- 
tained a pint of serum, a little yellow. The heart 
was very voluminous; the cavity of the left ventricle 
was more than twice as large as natural : its walls 
were firm, and thicker than in the normal state. The 



212 DISEASES OF THE AORTA. 

aortal valves, fungous and spread out like a cauli- 
flower, towards their free edge, offered at their base 
hard and cartilaginous points. The vegetations which 
bordered this triple valve were soft, of a grayish 
white, and were raised, or rather torn, with great 
facility. 

The other cavities of the heart appeared to be in 
the natural state. 

The vegetations of the valves of the right side are 
not very common: we find some examples of them in 
certain cases, which we have reported above. Their 
effects, their symptoms, thejr treatment, being the 
same as those of the vegetations of the left valves. 
We shall now pass on to the general history of the 
diseases described in this article. 



ARTICLE II. 

GENERAL HISTORY OF THE INDURATION, AND OF THE VE- 
GETATIONS OF THE VALVES OF THE HEART, AND OF THE 
CONTRACTION OF ITS DIFFERENT ORIFICES. 



Section I. — Anatomical Description of the Induration of the 
Valves of the Heart in general. 

The characters presented by indurations of the 
valves vary accordingly as they affect the valves in 
the whole of their extent, or some parts only; ac- 
cording to the direction which they impress on these 
organized valves, that is to say, according as they 
are approximated to or removed from the orifice to 



DISEASES OF THE AORTA. 213 

which they are affixed; and, lastly, according to the 
different degrees of induration. When they are af- 
fected throughout their whole extent, they are en- 
tirely deformed, or evoluted, representing a kind of 
ring, or elliptical border, or, in some cases, a kind 
of button-hole, with edges of various thicknesses, re- 
sembling the lips of the glottis, the opening of which 
is frequently not more than three or four lines in its 
greatest diameter. The surface of the induration is 
smooth and polished, unless when the degenerescence 
is complicated with the existence of vegetations, or 
osseous asperities. In this state, the texture of the 
valves and their fibrous circles present, sometimes, 
a truly cartilaginous hardness, and at other times the 
consistence of fibro-cartilage, or only that of tendon: 
it cracks under the dividing instrument, and the as- 
pect of the divided surface varies according as the 
induration is tendinous, fibro-cartilaginous, or carti- 
laginous. In a more advanced degree, this kind of 
induration is transformed into a species of ossifica- 
tion, of greater or less extent : in some cases, a con- 
siderable portion of the valve does not present any 
alteration; whilst the duplicature of its base, or rather 
the fibrous zone, is already partly cartilaginous, or 
even ossiform, or at least incrusted with some calca- 
rious concretions : at other times, the base is perfect- 
ly healthy, whilst the processes and indentures of the 
valves have taken on the transformations indicated. 
The valvular processes sometimes adhere, or blend 
together, so as almost completely to obliterate the 
orifice. Often, we only find between the flaps of the 
valves simple depositions or layers, more or less ex- 
tensive, of phosphate of lime, the whole of which are 



214 DISEASES s OF THE AORTA. 

united in one piece. These plates are, ordinarily, 
covered by the internal membrane; but we see them, 
sometimes, in immediate contact with the blood. It 
is not uncommon to meet, on the free edge of the 
valves, with a greqt number of small cartilaginous 
grains, or osseous, globular, or pisiform concretions. 
The valves, thus altered, present quite a marked 
redness. It is evident, that, in such a state of mal- 
formation and hardness, they are unfitted to carry on 
the important functions which nature has confided to 
them. 



I.— INDURATION OF THE MITRAL AND SIGMOID AORTAL 

VALVES. 

The induration of these valves, which we shall de- 
nominate the left, or arterial valves, is much more 
frequent than that of the right, or venous valves. To 
what can we attribute this remarkable difference? 
According to the author of the Essay on the Or- 
ganic Diseases of the Heart, it proceeds from the 
circumstance of the left valves having an organiza- 
tion more decidedly fibrous, and better calculated to 
receive the matter which transforms them into carti- 
lage, or the calcarious salts, which gives them an os- 
sious or stony hardness. This explanation, or rather 
this hypothesis, is far from being satisfactory. The 
more efficient, and perhaps the real cause of this 
difference, may depend upon the unequal activity of 
the left and right cavities, and in the difference of 
the blood which passes through them. The left ca- 
vities receive a more rigorous, exciting, and irritant 
blood, than that which permeates the right cavities: 



DISEASES OF THE AORTA. 215 

it is not, therefore, very astonishing that their valves 
should be those for which the osseous induration af- 
fects an unfortunate predilection, especially if we 
admit the opinion extremely probable, according to 
which we have considered this morbid alteration as a 
consequence, or termination of a slow phlegmasia. 
However this may be, the induration offers some pe- 
culiarities, accordingly as it has its seat on the mitral 
or semilunar aortic valves, which is evidently to be at- 
tributed to the difference naturally existing between 
them. It is particularly in the induration of the 
first, that we observe the different conditions we have 
above described. We have, sometimes, seen the in- 
duration confined to the tubercles of Arantius, dege- 
nerated, in that manner, about the size of a common 
pea. At other times, we have found a kind of stony, 
pyramidal, or twisted concretions, which projected, 
in the manner of stalactites, in the cavity of the aor- 
ta, or the heart; whilst, by one of their extremities, 
they were implanted in the base of the valves, or 
forced, more or less deeply, into the substance of the 
ventricle. In one instance, we have found the aortic 
valves, for the most part, detached and loose. On 
examining the arterial valves, we have been enabled 
to distinguish four different forms of induration; the 
differences in which depend, perhaps, upon the varia- 
ble proportions of animal matter, and of the phosphate 
and carbonate of lime, which enter into its composi- 
tion. The first form constitutes the conversion of 
the valvular tissue into a tendinous, fibro-cartilagi- 
nous, or cartilaginous substance. In the second, 
merely an exhalation of calcarious salts takes place 
on the surface of the membranes. In the third, 



i 



216 DISEASES OF THE AORTA, 

the calcarious substance is seated deeply within the 
valves. Lastly, the fourth form is characterized by 
an ossification, which seems to be more allied to the 
laws of normal osteogeny, in which the osseous state 
succeeds to a state at first cartilaginous; consequent- 
ly, this fourth form is only the first, arrived to a more 
advanced stage; and it is with reason that the yellow 
or cartilaginous indurations have been regarded as 
the rudiments of ossifications, inchoamenta ossifica- 
tionis. When the induration is situated on the mi- 
tral or sigmoid valves, they are sometimes more or 
less depressed; at other times, more or less elevated: 
from whence results a variable contraction of the ori- 
fices. It has appeared to us, that, in # general, the 
deformed valves project forward, in such a manner 
as to form a kind of arch, or infundibulum, in a di- 
rection corresponding with the course of the blood. 
Thus, we have seen the bicuspid valve pushed, (if 
we may be allowed the expression,) so as to form a 
projection within the ventricle; while we have seen 
the sigmoid valves distorted and turned backward 
towards the walls of the aorta. Nevertheless, we 
have observed, also, an inverse tendency for the lat- 
ter; as if, during the systole of the aorta, the blood 
had flowed backward towards the ventricular cavity. 



11.— INDURATION OF THE TRICUSPID VALVES* AND OF 
THE SIGMOID VALVES OF THE PULMONARY ARTERY. 

We have already said, that the induration of the 
valves of the veins is less frequent than that of the 
valves of the arteries; but Bichat was wrong in de- 



DISEASES OF THE AORTA, 217 

nying the existence of them, as we have proved by 
facts. In general, the induration of the right valves 
is simply fibrocartilaginous, or cartilaginous. Some- 
times, however, we find in them partial ossifications. 
It has appeared to us that these ossifications, in gene- 
ral, coincide with an unnatural communication be- 
tween the left and the right cavities. If this remark 
be just, it confirms the idea we have advanced re- 
specting the cause of the frequent occurrence of 
ossification of the left valves, compared with that of 
the right. In such kind of communication, a certain 
quantity of red or arterial blood would pass into the 
right cavities, and produce more or less irritation. 

In some of the cases we have reported, the right 
valves formed a kind of partition or diaphragm, open 
in the centre, or towards the circumference. Far- 
thermore, most of the arrangements we have described 
when speaking of the induration of the valves of the 
arteries, are also met with in cases of the hardening 
of the right valves: hence the reason why it would 
be useless to dwell any longer on this subject. 



SECTION II. 

ANATOMICAL DESCRIPTION OF THE VEGETATIONS OF THE 
VALVES OF THE HEART IN GENERAL. 

The valvular vegetations have been designated, by 
M. Laennec, by the name of varicose vegetations. 
This denomination, it appears to us, should have been 
adopted, because these kinds of excrescences have an 
appearance very similar to that of warts; and espe- 

28 



218 DISEASES OF THE AORTA, 

cially to that of those venereal excrescences which 
are observed on the genital organs. They vary in 
colour, size, number, form, consistence, more or less 
adhesion to the valves, and in their mode of forma- 
tion. They are, ordinarily, of a greyish or yellow- 
ish white , colour, relieved, wholly or in part, by a 
more or less bright red colour : their size, very much 
like that of tubercles, varies from the size of millet 
seed to that of a pea: their number is subject to great 
variations. We find them, sometimes, isolated: at 
other times united together, clustered, or agglome- 
rated, in such a manner as to resemble cauliflowers. 
They have, in general, a rounded, granular form, 
with a smooth and sometimes unequal surface. Some 
of them are soft, easy to crush, and may be detached 
by the slightest traction, as if they had not had suffi- 
cient time to become organized. These granulations 
have appeared to us to have much analogy with those 
of the serous membranes so frequently met with in 
cases of chronic inflammation. The resemblance is 
sometimes so striking, that there would be consider 
ble difficulty in distinguishing them, as we have been 
assured, when comparing the granulations of the 
pleura and pericardium with the valvular vegetations 
met with in the same subject. We might give to 
these vegetations the name of albuminous vegeta- 
tions. 

Other vegetations present greater resistance : with 
a little force we may, however, separate them from 
the valve without destroying them. They are from 
three to four lines in diameter; and their figure, in- 
stead of being globular, is cylindrical, or pyramidal. 
They are, probably, those excrescences, which, in 



DISEASES OF THE AORTA. 219 

the infancy of pathological anatomy, were taken for 
Worms. 

Finally^ others have contracted such an adhesion 
with the valves; or rather have become so deeply 
rooted in them, that we frequently can only remove 
them by tearing them with the nails, or cutting them 
with the scalpel. To these will apply, exclusively, 
the name of varicose. 

The vegetations select the free edge of the valves, 
in preference to any other parts of these membranous 
organs. We find them sometimes, however, on the 
whole extent of the internal membrane of the auri- 
cles, and on the pericardium. They contract the 
orifice of the valve, in proportion to their number 
and their volume. They are met with more fre- 
quently in the aortic valves than elsewhere. 

According to M. Laennec, these vegetations are 
formed by a kind of organization of polypous or fibri- 
nous concretions deposited on the surfaces of the 
valves and the auricles, in consequence of some dif- 
ficulty of the circulation. It will not be disputed, 
that they may be sometimes formed in this manner; 
but it appears to us equally certain, that these vege- 
tations are often nothing else than the result of the 
organization of a puriform, albuminous exhalation, 
secreted by the inflamed valvular or auricular mem- 
brane. This mode of formation appears to us the 
more probable, as the vegetations have a great ana- 
logy, as we have already noticed, with the albumi- 
nous granulations which are observed to follow the 
serous phlegmasia. The phlegmasia of the internal 
membrane of the aorta and left cavities of the heart 
being so much more frequent than that of the inter- 



220 DISEASES OF THE AORTA. 

nal membrane of the pulmonary artery and right ca- 
vities, we may easily conceive how it happens that 
the vegetations are met with most frequently on the 
aortic and mitral valves. It would seem that the 
contrary ought to be the fact, if the vegetations are 
formed constantly, according to the mode prescribed 
by M. Laennec; because the polypous concretions 
are much more common in the right cavities of the 
heart than in the left. What confirms us still more 
in our opinion, is the case of varicose vegetations on 
the mitral valve and the left auricle, related by M. 
Laennec himself. In fact, as it appears to us, there 
existed in this case a phlegmasia of the internal mem- 
brane of the aorta and the auricle; " because the sig- 
moid valves of the aorta and internal membrane of 
this artery offered a very deep red colour, which 
contrasted with that of the ventricle, which was of a 
pale red, and almost yellow. The left auricle of- 
fered, in the whole extent of its internal surface, this 
same deep red colour. This surface, for the extent 
of about an inch square, as well as the free edge of 
the mitral valve, was covered with vegetations, some 
of which were slightly rose-coloured, or violet, and 
as if injected with small vessels. At their free ex- 
tremity, a number of them presented small clots of 
coagulated and black blood, strongly adherent."* 

This very remarkable case seems quite proper to 
prove, that the vegetations may have been produced 
in the manner we have indicated. The fibrinous 
concretions adherent to the extremity of the vegeta- 
tions do not invalidate in the least our explanation : 

* Work, cited torn, ii, pp. 242, 243. 



DISEASES OF THE AORTA. 221 

they rather serve to support it; since we have alrea- 
dy clearly shown, and shall presently demonstrate, 
that inflammation is one of the circumstances which 
has a leading influence in most cases of concretion of 
the blood. 



SECTION III. 

OF THE SYMPTOMS AND DIAGNOSIS OF INDURATION, AND 
VEGETATIONS OF THE VALVES OF THE HEART. 

We shall unite, in one view, the indurations and 
vegetations of the valves, in relation to their diag- 
nosis; because one of the constant and common ef- 
fects of both is more or less contraction of the 
orifices of the heart, and because the signs which 
characterize them result from the mechanical obsta- 
cle which this contraction opposes to the circulation. 
It is, farthermore, evident that the valves loaded 
with vegetations, or converted into a cartilaginous or 
osseous structure, become unfit to perform the move- 
ments of elevation and depression, without which the 
circulation cannot go on in a regular manner. The 
diagnosis of indurations and vegetations of the valves 
of the heart, or, if you wish, of contraction of the ori- 
fices of the valves, has always been regarded as very 
difficult and obscure, if not perfectly impossible. We 
hope, however, that every one, after having read 
this article attentively, will be convinced that this 
disease is one of those which may be most easily as- 
certained in the present day. 

The beautiful work of Corvisart does not give any 
mode of ascertaining with precision the contraction 



222 DISEASES OF THE AORTA. 

of the right orifices. In this case, in fact, the ex- 
ploration of the aortic pulse, or of the great circula- 
tion, which Corvisart regards as the source of the most 
certain signs of contraction of the ventriculo-aortic 
orifice, is found useless for ascertaining that of the 
ventriculo-pulmonary orifice : it would be necessary 
to explore the pulmonary pulse, or the smaller cir- 
culation, which is altogether impossible, 

" Could we examine," says Corvisart, "the pulsa- 
tions of the pulmonary artery, or its branches, in the 
same manner as we do the pulsations of the aorta, or 
its branches, we should recognise, with equal ease, 
both the contractions of the right orifices of the heart, 
and those of the left. The obscurity which envelops 
the symptoms of contraction of the right orifices, is 
never entirely dissipated at the time it becomes re- 
quisite to ascertain an imperfect obliteration of the 
left auriculo-ventricular orifice. However, some pe- 
culiar symptoms will enable us to recognise this af- 
fection. Of this number is a peculiar stridor, diffi- 
cult to describe; sensible to the hand, when applied 
to the precordial region, and even to the hand which 
feels the pulse, but in a less distinct manner. Far- 
thermore, the pulse is less regular than in the case 
of contraction of the right orifices, but less irregular 
than when the aortic orifice is altered. In the case 
of contraction of the aortic orifice, the pulse may 
preserve a certain degree of hardness and rigidity, 
but never much plenitude or regularity. This con- 
stant and permanent irregularity will always suffice 
to establish an accurate diagnosis of the contraction 
of the mouth of the aorta. Here there is no obscu- 
rity, and when the physician has no other guide than 



DISEASES OF THE AORTA. 223 

this kind of undulation, stridor, heavy tremor, this 
easily distinguished character of the pulse, in all 
cases of this kind, his diagnosis can no longer be un- 
certain." We may be permitted to say, that we 
here find the illustrious physician slightly contra- 
dicting himself. In fact, he gives for the diagnosis 
of contraction of the aortic orifice almost the same 
signs as those which he has above pointed out for the 
contraction of the left auriculo-ventricular orifice: 
but it happens that the obscurity which envelops the 
symptoms of contractions of the right orifices are not 
entirely dissipated at the moment we wish to ascertain 
that of the left auriculo-ventricular orifice :" there- 
fore it will not be entirely dissipated when it is re- 
quired to ascertain the contraction of the mouth of 
the aorta, the signs of which, according to him, are 
essentially the same. But this is not all; it is diffi- 
cult to feel this particular character of the pulse no- 
ticed by Corvisart. M. Laennec assures us, that he 
has never been able to perceive it even in subjects who 
presented in the most evident manner, in the pre- 
cordial region, the above-mentioned tremor; which, 
according to the same author, is only sensible to the 
hand in those cases where the contraction is very 
considerable. The result of all this is, that the signs 
pointed out by Laennec are not sufficient to charac- 
terize, generally, the contraction of the orifices of 
the heart; and they would never enable us to ascer- 
tain the contraction of each of the orifices in particu- 
lar. Lasting honour should, however, be rendered 
to this profound observer; — for, although it be true 
that he has not entirely torn aside the veil which has 
so long enveloped the diagnosis of the diseases of the 



224 DISEASES OF THE AORTA. 

valves of the heart, he is at least the first who has 
drawn aside its folds. It is certain that the charac- 
ters of the pulse indicated by Corvisart, the rushing 
murmur of the precordial region, are exceedingly 
valuable symptoms which ought not to be neglected. 
The same is true of the defect of harmony, the spe- 
cies of contradiction, if we may be allowed the ex- 
pression, which exists between the pulsations of the 
heart and those of the pulse, in the affections of which 
we are speaking. We have, now and then, been able 
to suspect a contraction of the orifices of the heart 
by means of this symptom; that is, by observing the 
very strong pulsations of the heart coinciding with 
the extreme smallness of the pulse. But we must 
acknowledge that this symptom is met with in diffe- 
rent diseases from those which at present occupy us. 
There is a method of exploration for ascertaining the 
contraction of the several orifices of the heart, which 
no other can supply : we refer to auscultation, either 
immediate or mediate. The symptoms which this 
mode of exploration furnishes, already pointed out 
by M. Laennec, are the following: 1st, When the 
disease affects the auriculo-ventricular orifice, we 
hear, during the contraction of the auricles, which 
continues longer than in the natural state, a very 
distinct sound, which resembles the sound of a blow 
given by a file on wood, or that of a bellows quickly 
pressed. 2nd. When the contraction is situated about 
the arterial orifices (ventriculo-pulmonary and aor- 
tic,) the sound of rubbing, to be presently described, 
is the same; but it is coequal with the contractions 
of the ventricles, and of the pulse. 3d. If the left 
orifices are contracted, the pathognomonic sound will 



DISEASES OF THE AORTA. 225 

be heard more especially in the region of the carti- 
lages of the fifth, sixth and seventh ribs: whereas, if 
the contraction occupies the right orifices, the same 
sound will be more particularly heard at the inferior 
part of the sternum. 4th. The bellows-sound appears 
to coincide with the cartilaginous, or fibro-cartilagi- 
nous induration, and with the contraction produced 
by vegetations; that of the file, on the contrary, an- 
nounces rather the contraction produced by open in- 
duration. 

We have so frequently had occasion to confirm the 
absolute certainty of these symptoms, they have ena- 
bled us to ascertain the contractions of the orifices 
of the heart with so great facility, that we do not fear 
to repeat, that the diagnosis of this disease may be 
established in the most positive manner. We allow, 
only, that cases now and then occur, in which it is 
somewhat embarrassing to designate with precision 
which is the orifice constricted : but, on supposing 
that this cannot be determined, the inconvenience 
would be of no consequence. The only thing truly 
important is to know whether any orifice be con- 
tracted. Now, it is always possible to arrive at this 
certainty, by means of the symptom which has been 
so frequently indicated. It has never failed us, it 
has never deceived us. We have reported six cases 
in which the autopsy has demonstrated its exactness. 
We might augment the number, if it appeared ne- 
cessary; and this would be of much consequence, if 
the contractions of the orifices of the heart were a 
rare disease.* 

* It sometimes happens, that we hear a bellows-sound in the precordial 
region, without there being contraction of the orifices; but then this sound 

29 



226 DISEASES OF THE AORTA. 

Nothing appears to us more easy to be conceived/ 
than the mechanism of the sound which accompanies 
the constriction of the orifices of the heart. The 
blood being obliged to pass from the cavity of the 
auricles or the ventricles, across a very narrow open- 
ing, must necessarily produce more or less friction; 
and it is precisely this friction which produces the 
murmur, or jarring thrill of which we have spoken. 
In the same manner we may explain the vibratory 
tremor, which is heard in the precordial region, and 
which M. Laennec has justly designated by the term 
purring tremor (fremiscment catairc*) because it so 
nearly resembles the sound produced by cats when 
the hand is drawn kindly over their back, in which 
they respond to such caresses by the peculiar rale 
which every one may have observed.* 

The symptoms we are about to offer, are the only 
ones which characterize and specify the contractions 
of the orifices of the heart. But there are others 
which remain for us to make known, derived from 
the influence which this affection exercises upon the 
functions in general, and especially on those of the 
circulating system. These symptoms are not less 
constant, for the most part, than the preceding, but 
they are much less important for diagnosis: they are, 
indeed, very equivocal, as they are common to all 

only takes place at intervals; and this circumstance is sufficient not to con- 
found it with that produced by the contraction, which is heard continuously. 
* The intermittance, inequality and irregularity of the pulsations of the 
heart, are observed, more particularly, in the cases of lesions and contrac- 
tions of its orifices. U would be superfluous to offer, in this place, any 
cases relative to this subject; but we would request the reader to consult the 
article relative to it, in the work of M. Laennec. — Traite de FAuscult. Med* 
torn. ii. p. 230, et suhantes. 



DISEASES OF THE AORTA. 227 

diseases which produce an obstruction to the circu- 
lation, or even the respiration. These symptoms 
have been given by many authors, as peculiar to an- 
eurism of the heart: which is a great error; for, in 
these cases, aneurism of the heart, if it exists, is far 
from being the first cause of the phenomena observed, 
it is only one of the effects, or, if we may be permitted 
the expression, accidents of contraction of the orifices. 
We have frequently described the phenomena in ques- 
tion, in several preceding cases. Nevertheless, we 
are obliged again to present a rapid sketch of them. 

A. Influence on the Circulation. 

We have already pointed out some of the symp- 
toms furnished by the circulation, at the beginning 
of this article : we shall consider them here. The pa- 
tients, affected with contraction of the orifices of the 
heart, suffer palpitations more or less violent, more 
or less frequent, more or less prolonged; and which 
the least exercise, the least emotion, renders much 
more sensible. The pulse, small, hard, unequal, irre- 
gular, and intermittent, contracts by its small degree 
of fulness, with the pulsations, frequently energetic, 
of the heart. It is less irregular, when the disease 
affects the right orifices, than when it affects the left. 
The blood can no longer traverse freely the circu- 
lating centre, obliged, as it were, to flow back upon 
itself, distending the lungs, the pulmonary artery, 
the right cavities of the heart, the large veins, and 
all their branches: thence the serous infiltration, and 
even passive hemorrhages: thence the lividity, and 
violet injection of the face, which have been too ge- 
nerally regarded as the infallible symptoms of disease 



228 DISEASES OF THE AORTA. 

of the heart, and which do not indicate any thing 
more than an impediment to the circulation: thence 
a yet greater injection of almost all the mucous mem- 
branes: thence a swelling of the brain, and sub-apo- 
plectic symptoms: thence a similar swelling of the 
liver.* These symptoms are all so easily explained, 
according to the laws which preside over the mecha- 
nism of the circulation, that we think it unnecessary 
to give a more particular analysis of them. 

B. Influence on Respiration. 

A slight dyspnoea, which patients designate by the 
name of short breath; panting, after more than usual 
exercise, after having gone up stairs, for example, 
are the first derangements of respiration; but soon 
the disorder augments and increases until the most 
painful dyspnoea and the most distressing suffocation 
supervene: whence the name of asthma, by which 
the vulgar know this disease, and the energetic, ex- 
pression of one of our patients, who affirmed that he 
strangled rather than breathed. f 

C. Influence on Locomotion and Innervation. 
The disorders of these functions are intimately 
connected with those of respiration, and are, in some 
measure, proportional to them. Who can portray 
the picture of the unfortunate man suffering from the 
anguish of extreme contraction of the orifices of the 
heart? The despair, horror, fright and. anxiety ex- 

* Pulsations of the jugular veins are frequently observed in the case of 
lesion of the orifices of the heart, and always indicate an embarrassment of 
the circulation, but not the situation of the obstacle. 

\ The dyspnoea depends, principally, on the distention of the blood ves- 
sels of the lungs. 



DISEASES OF THE AORTA. 229 

pressed in every feature; his eyes protruding, hag- 
gard, distorted; his eyebrows raised; the nostrils di- 
lated; his mouth open, as if to express his wish to 
respire, and the efforts which he makes to satisfy 
this urgent want: it is, for the same reason, and by a 
true synergy ) that all the muscles which concur to 
respiration, contract with extreme force: incapable 
of supporting the horizontal posture, the superior 
limbs fixed on the bed, to give a point of support to 
the inspiratory muscles, the trunk strongly bent for- 
ward; he utters the most plaintive groans, and, with 
an uninterrupted voice, not unfrequently accuses 
the inefficiency of medicine, implores death, and 
would even hasten it himself, if his failing strength 
and the circumstances surrounding him would per- 
mit. He no longer tastes the pleasures of sleep; or, 
if he should happen to fall into a doze, is tormented 
by painful dreams, and awakes as if by sudden sur- 
prise. In some cases, he experiences moments of re- 
laxation; and, during this kind of truce, truly deli- 
cious, he cherishes the happy idea of an approaching 
cure; but a new attack of asthma soon dissipates all 
his hopes. In the mean time, after efforts, of which 
the conservative power is alone capable, the muscles 
of respiration at last fall into a state of exhaustion, 
like all the rest. The patient, incapable of the least 
motion, can no longer sustain himself: his body, obey- 
ing its own weight, falls on the bed, no more to rise: 
his voice is extinguished, his eyes are tarnished, and 
the features discomposed — he expires; — too happy, 
if a sudden death has spared him the long-continued 
pains which we are about to describe. 

We have not spoken, in all that precedes, of the 



230 DISEASES OP THE AORTA. 

pain which may accompany the presence of the dis- 
eases of the .orifices of the heart. We ought to say 
here a few words respecting them. Pain, a symp- 
tom so frequently unfaithful in many diseases, is only 
of very feeble assistance in forming a diagnosis of the 
contraction of the orifices of the heart. In many 
cases, we observe not altogether pain, but a sensation 
of embarrassment, of inexpressible pressure in the 
precordial region. We occasionally see, however, 
patients who suffer a deep-seated lancinating pain, 
corresponding with the pit of the stomach, which 
might mislead those who are too much disposed to see 
almost every where inflammations of the stomach. 
Lastly; it happens, also, that patients do not com- 
plain of any kind of suffering in the region of the 
heart. However this may be, whenever pain exists 
it is a new motive to lead us to consider indurations, 
and some of the vegetations of the valves, as the re- 
sult of a phlegmasia, more or less chronic or sub- 
acute. 

If it be extremely easy to recognise these diseases 
when they have produced a considerable contraction 
of the orifices, it is much less so when they have only 
begun to be developed. In every case, a slight, ha- 
bitual dyspnoea, which augments on the least exer- 
cise, palpitations, the cough and choked sound which 
accompany the contractions of the heart, a little oede- 
ma about the malleolse, with the knowledge of previous 
circumstances, are data, which permit us at least to 
suspect the disease, and which invite us to use the 
means most proper to remove it. 



DISEASES OF THE AORTA, 231 



SECTION IV. 

OF THE CAUSES OF THE VEGETATIONS AND INDURATIONS 
OF THE VALVES OF THE HEART. 

The causes of these diseases are essentially the 
same as those which determine the affections of the 
aorta, of which we have already given some account. 
It would, therefore, be to employ superfluous repe- 
tition to return to them in detail : w r e shall only say, 
that external violence to the precordial region, phleg- 
masia of the precordium and neighbouring organs, 
too fatiguing exercise, are causes, the frequency and 
activity of which cannot be too often stated. 

The syphilitic virus has been regarded, in these 
latter timfes, as the most common cause of many of the 
diseases of the heart and vessels, and especially of val- 
vular vegetations. We will not deny the influence of 
such a cause — but, founded on the practice and ob- 
servation of twenty years at the hospital des Veneri- 
ens, we dare to affirm that the influence of the above 
cause has been exaggerated. We have opened many 
individuals who had been affected with venereal dis- 
eases, without finding any vestige of vegetation of the 
valves; and we have encountered this lesion in per- 
sons who have never been affected with syphilis; and 
in a young girl, particularly, who possessed all the 
physical signs of virginity. We should, therefore, 
admit with great reserve, and much restriction, the 
opinion of MM. Corvisart, Scarpa, and others, on 
the nature of the vegetations of the valves and other 
diseases of the blood vessels* 



232 DISEASES OF THE AORTA. 



SECTION V. 

OF THE TREATMENT OF VEGETATIONS AND INDURATIONS 
OF THE VALVES. 

When the nature of a disease is known, it is evi- 
dent that it is on this knowledge that the treatment 
ought to be supported. All our methods, in fact, 
ought to proceed in the inverse ratio of the immedi- 
ate causes of the disease: but a multitude of conside- 
rations, which we have brought to light elsewhere, 
have influenced us to believe that very frequently 
the morbid changes in the valves take place, in fact, 
under the influence of phlegmasia: consequently, 
their treatment ought to be more or less antiphlo- 
gistic. It should consist, therefore, of general and 
local bleeding, of rather a strict diet, preparations of 
digitalis; in one word, of the same means which we 
have recommended in the treatment of aortitis, and 
its effects. 

It would be useless to inform our readers that the 
treatment cannot have satisfactory and complete re- 
sults, excepting so far as it is applied to the origin of 
the disease. But, when this is much advanced, the 
changes in the valves are much advanced, the con- 
traction of the orifices has reached a high degree; 
consequently, the only success which we can expect 
from the best regulated means is to relieve the pa- 
tients a little, and to prolong, for a certain time, their 
painful existence. All the agents, hygienic and the- 
rapeutic, ought no longer to be employed, except as 
simple palliatives. 

We have frequently been able to remove the most 



DISEASES OF THE AORTA. 233 

urgent symptoms of diseases of the valves; such as 
dyspnoea, anhelation, infiltration, &c, by the em- 
ployment of sanguine evacuants, diuretic, aperient, 
anodyne medicines, pediluvia, revulsives, &c, se- 
conded by absolute repose of mind and body, and by 
a rigorous diet. But this cure, although it appears 
somewhat wonderful, is only momentary. The symp- 
toms are again renewed, whenever the patients give 
themselves up to any kind of excess whatever. We 
cannot too often repeat, that perfect repose is indis- 
pensable in the case of contraction of the orifices of 
the heart. It is still more requisite, when the pa- 
tients are oppressed by the least exercise; as we can 
safely assert, that the principal cause of diseases of 
the heart may be traced to violent and forced exer- 
tions; such as the chase, dancing, and all the profes- 
sions which require energetic and prolonged endea- 
vours. 

It is necessary to say, that, in this disease, as in all 
others, it is the cause which it is most important 
to combat. The physician ought, then, to seek out 
the cause with the utmost care; too happy, if, after 
having found it, he has the power to vanquish it! 
Farthermore, we should say, for the consolation of 
patients, that they may live a number of years with 
contraction of the orifices of the heart, unless it has 
arrived at an extreme degree. We think, also, that 
the physicians of the present day, being better in- 
structed in the true nature of indurations and vege- 
tations of the valves of the heart, and much more en- 
lightened as respects the diagnosis, are able to treat 
them with much greater advantage than has been 
done heretofore. In fact, it is especially at the com- 

30 



234 DISEASES OF THE AORTA. 

mencement of diseases of the heart, that we can hope 
to combat them with success; but it is auscultation, 
alone, which can furnish us with the means of ascer- 
taining these diseases at the very commencement of 
their existence. 

An invincible difficulty in the treatment of dis- 
eases of the heart, in general, is the continual action 
to which the organ is subjected. The first indica- 
tion, when an organ is diseased, is to place it in the 
most complete repose; but this indication it is evident- 
ly impossible to put in practice in the diseases of the 
heart. The absolute repose of this organ, this branch 
of the vital tripod, would be at once an inevitable 
cause of death both to it and every part of the indi- 
vidual whom it animates. In truth, the blood being 
the natural stimulus of the heart, the bleedings we 
have recommended, the anodynes and demulcent 
drinks, diminish this exciting power, and remedy, 
as much as possible, the inconvenience of being una- 
ble to resort to a method so efficacious and rational as 
that of which we shall presently speak — the repose 
of the suffering organ : these means do not permit an 
absolute repose, but they can reduce its action as 
much as is compatible with life. 



BOOK SECOND. 



THE DISEASES OF THE HEART. 



PRELIMINARY CONSIDERATIONS. 

In order to obtain an exact and complete idea of 
the anatomy and physiology of the heart, it is neces- 
sary to examine, separately and analytically, the 
structure and functions of the various parts which 
compose it; and, to form just and complete notions of 
the pathology of that important organ, it is indispen- 
sable to study, separately, the diseases of the various 
textures which concur in its formation. Corvisart 
has followed the method we are about to indicate; but 
he has not comprised in his division the pathological 
lesions of many parts which enter essentially into the 
structure of the heart; such as the arteries, veins, 
and nerves of the internal membrane of that organ. 
To render our classification as exact as possible, we 
have thought it our duty to divide the diseases of the 
heart into those which affect its internal membrane;* 
those which affect the external; those which are si- 
tuated in the muscular substance, which constitute, 

* We have considered, along with these, the diseases of the fibrous tis- 
which are met with in the duplications of that membrane 



236 DISEASES OF THE AORTA, 

properly speaking, its middle membrane; and in those 
which occupy its vessels, nerves, or cellular fatty 
texture. We have already given a history of the 
pathological lesions of the internal membrane. No- 
thing remains to us but to describe the others; which 
will form the subject of the following sections and 
chapters. 



SECTION I. 

DISEASES OF THE PERICARDIUM. 

This section will consist of two chapters. In the 
first we shall treat of pericarditis (inflammation of 
the pericardium,) and its consequences; the second 
will be consecrated to the study of hydro-pericardi- 
tis, and pneumo-pericarditis. Effusions of blood in 
the pericardium, being ordinarily the consequence 
or result of some other disease, rather than the pri- 
mitive or essential one, we have thought a particular 
chapter need not be consecrated to them. 



238 DISEASES OF THE PERICARDIUM* 



CHAPTER I. 

OF PERICARDITIS AND ITS CONSEQUENCES, SUCH AS AL- 
BUMINOUS EFFUSIONS, FALSE MEMBRANES, CELLULAR 
ADHESIONS, FIBROCARTILAGINOUS, OR CARTILAGIN- 
OUS MEMBRANES, OSSIFICATIONS OF THE PERICARDI- 
UM, &c. 



ARTICLE L 

PARTICULAR OBSERVATIONS RESPECTING PERICARDITIS, 
EITHER ACUTE OR CHRONIC. 



SECTION I. 
REMARKS ON ACUTE PERICARDITIS. 

We shall begin with a case of acute pericarditis, 
extracted from the manuscripts of Joseph Exupere 
Bertin, father of the author of this work. 

" In the course of the year 1739, a young man, 
aged from sixteen to seventeen years, after having 
ridden post for several days, was taken, on his arrival 
in Paris, with excessive pain, and extreme difficulty 
of respiration; his pulse was bad, and denoted sud- 
den death. This young man became gradually weak- 
er every moment, and, finally, died in the course of 
two days. 

" I examined the body, in presence of M. Hu- 
nauld, who suspected a polypus in the pulmonary 
artery. We found, on the whole surface of the heart 
and auricles, a layer of lymphatic substance, rather 
compact, and about the thickness of a dollar. The 
remainder of the pericardium is filled with a bloody 



DISEASES OF THE PERICARDIUM. 239 

serum. On opening the pleura, I found the same 
thing on the whole surface of the lungs, and a great 
deal of bloody serum effused in the cavity. " 

This case, although it leaves many details to be de- 
sired, offers us, nevertheless, some of the most pro- 
minent symptoms of pericarditis : the inspection of 
the body proves that such was, in fact, the nature of 
the disease. The mortal anguish, the extreme dys- 
pnoea, the constant fainting, the bad pulse, are suffi- 
ciently certain, if not infallible signs of pericarditis. 
We say that these symptoms are not infallible, be- 
cause, in fact, we sometimes meet with them in pleu- 
risies not complicated with pericarditis. Nothing, 
in other respects, is more frequent than such a com- 
plication, and it is the reason why authors have so 
frequently confounded these two diseases. The case 
we are about to cite is itself a new proof of the com- 
plication to which we allude. Nothing is, in fact, 
more rare than cases of pericarditis exempt from com- 
plication : here, however, is one which we shall pro- 
ceed to relate. 

Case LXIV. 
Acute Simple Pe?icarditis. 

Laurent Barthelemy, twenty-six years of age, was 
admitted to the hospital Cochin on the 20th of July, 
1818, treated a short time before, at la Pitie, for a 
catarrhal affection. He complained of insupportable 
pain in the side; his face was pale, and pinched; re- 
spiration was short and very painful at each inspira- 
tion, the painful part, which was on the left side, be- 
came more insupportable, and drew tears from the 
patient; the chest gave a flat sound on this side, a 
little more clear at the right; the sputa were mucous, 



240 DISEASES OF THE PERICARDIUM. 

frothy and mixed with bloody striae. The patient 
kept himself bent forward in order to breathe more 
easily; it was impossible for him to lie down in his 
bed; the pulse was small, contracted, but regular. 
Twenty leeches were applied to the painful part on 
the first days of entrance. Notwithstanding, the pain 
continued, dyspnoea increased, and the patient passed 
the following night in a state of inexpressible anxiety. 
A blister applied the next day procured momentary 
relief. The pleuritic pain disappeared; but the dif- 
ficulty of respiration and emaciation augmented: we 
observed alternations of diarrhoea and constipation: 
In the last case, the symptoms were exasperated, and 
the dyspnoea and anxiety considerably increased. 
Lastly, about a month after entrance, the patient 
died. The inspection of the body was made by MM. 
Pichon and Belmas. 

Internal Condition. — No infiltration, abdomen 
only a little swollen. 

Thorax. — After having raised the sternum and 
cartilages of the ribs, we observed an immense pouch, 
extending more to the left than right, where it occu- 
pied, nevertheless, a very extensive space. The right 
lung was crowded upward, but much less in compa- 
rison, with that of the left lung, which did not occu- 
py more than a twentieth part of the left thoracic 
cavity. The whole pouch, formed by the pericar- 
dium, was seven to eight inches broad, five deep, and 
ten or eleven inches long: on opening its walls, there 
flowed out at first a little turbid serum, in which float- 
ed flakes of albumen, and soon some pus the odour of 
which was so infectious that we could not stay in the 
room. The heart, compressed, shrunk and appa- 
rently atrophied, occupied' only a very small space 



DISEASES OF THE PERICARDIUM. 241 

in the cavity of the pericardium, and was less than 
half the natural size. The serous membrane, which 
covered it, was very thick and covered with a puru- 
lent and friable false membrane. The pericardium 
itself, in the whole of its extent, had acquired a very 
considerable thickening, (about six lines.)* 

The pleura and lung were, in other respects, 
healthy. 

Case LXV. 

Pericarditis, Complicated zvith Granulations in the Lungs. 

Henry Meunier, domestic, aged seventeen years, 
was admitted to the hospital des Veneriens the 30th of 
March, 1811 : he was affected with chancres on the 
glans and free edge of the prepuce, and with inflam- 
mation of this last part. After twenty-four hours' 
treatment, the principal surgeon had him carried to 
the Infirmary of Medicine. This young man expe- 
rienced, at that time, a dry and frequent cough, 
and wandering pains in the right side of the chest; 
there was nausea and a saburral state of the tongue. 
The physician, who officiated in our stead that 
day, prescribed an emetic and demulcent anodyne 
drinks. Two days afterwards all the symptoms 
were aggravated. The pain having seemed to be 
fixed on a single point of the right chest, we applied 
a blister there, which did not appear to produce any 
other effect than to scatter the pain and render it 
more general. The symptoms increased in intensitv. 
In the evening, and during the night, the dyspnoea 

* The thickness of the pericardium, indicated by MM. Belmas and Pi- 
chon, depended, very probably, on the presence of false membrane adhering 
to its internal surface. 

31 



242 DISEASES OF THE pericardium. 

became extreme, accompanied with the most acute 
anxiety and almost absolute impossibility of remaining 
two minutes, in succession, in the same position. The 
cough became more frequent, and assumed a convul- 
sive character; the expectoration was more abundant 
and puriform; the face became swollen, a general 
c&dema appeared, the pulse was constantly small and 
convulsive, and the patient, in a short time, died. 

Inspection of the Body. — The pleura costalis ad- 
hered at almost all points, with the pleura pulmona- 
lis, by dry false membrane, which appeared to have 
been of long standing. 

The pericardium was distended by a turbid and 
reddish serum. The serous membrane, thickened and 
of a rose-colour, was covered with soft reddish con- 
cretions, removable with great facility: on the fold 
which covered the heart, very large long concretions^ 
had the appearance of fungous vegetations, and some 
were notched like the crest of a cock; one would 
have thought, at first, that these albuminous concre- 
tions, were united with the texture of the heart, or, 
at least, with its membrane, and were apparently 
identified with it, but we easily tore it away by pull- 
ing very lightly, and without disturbing the continu- 
ity, and we then observed it underneath the reddish 
serum, and three to four times thicker than in the 
natural state. On cutting through this, we distin- 
guished perfectly the line of demarcation, which 
separated it from the fleshy fibres of the heart, which 
were perfectly healthy. 

The lungs were in a state rather difficult to de- 
scribe; we did not perceive any tubercles to the 
touch, but we discovered in them small grayish very 



DISEASES OF THE PERICARDIUM. 243 

numerous points, and two or three inconsiderable vo- 
micae of purulent matter; they were swollen with 
reddish and frothy fluid, and even a little carnefied 
at the superior and posterior part. 

Meunier presented, on entering the infirmary, the 
symptoms of a catarrhal gastric affection, and the in- 
flammation of the pericardium was enveloped in pro- 
found obscurity, which was not removed either by 
the dry cough, or the wandering pains of the chest. 
The symptoms of gastric embarrassment contributed 
still more to remove every idea of inflammation, and 
seemed to indicate a treatment, which could not but 
aggravate the principal disease. However this may 
be, after the use of an emetic, the disease appeared, in 
fact, to augment in intensity, without any thing having 
announced to us its true character. A local pain was 
felt, it is true, but it did not correspond with the 
seat of the disease demonstrated by the autopsy, and 
it seemed to announce merely a pleuro-pneumonia 
of the right side, which decided us to prescribe two 
bleedings in the arm, and the application of leeches 
to the painful part. Lastly, the dispersion of the 
pain, on the application of a blister, made us suppose 
that we only had to contend with a pleurodynia. 

In the meanwhile, the violent symptoms augmented, 
the anxiety was at its height, and the cough convul- 
sive; the patient could no longer keep the horizontal 
posture; every circumstance announced that the dis- 
ease was of a more severe character than had been 
suspected. Lastly, the abundant expectoration, and 
its puriform character, lead us to suspect the existence 
of acute phthysis, and so much the more readily, as 
we could not obtain from the patient any positive in- 



244 DISEASES OF THE PERICARDIUM. 

formation respecting his previous condition. The 
autopsic examination proved, farthermore, the exist- 
ence of granulous phthisis, and that some portions of 
the lungs had been already affected with inflamma- 
tion. It is evident, from all the circumstances, that 
the disease of which Meunier died was, for the most 
part, situated in the pericardium, and that the phleg- 
masia was by no means propagated to the proper 
structure of the heart. 

It is unfortunate, for the certainty and precision 
of diagnosis, as well as for the nosography, that we 
have not had more frequent opportunities of observing 
simple pericarditis, we mean distinct from every 
other disease. Happily, in most cases, the same 
treatment is proper both in pericarditis and those 
complications which obscure the diagnosis. The 
most common complications consist, in fact, of phleg- 
masia of the other organs, particularly of the pleura 
and lungs. 

The following case offers an example of pericarditis, 
with inflammation, most probably, of the proper tex- 
ture of the heart: it wants the details, because the 
patient was not seen until a long time after the ori- 
gin of the disease, and when the symptoms, which 
would have enabled us to have recognised it, no 
longer existed. 

Case LXVI. 

Pericarditis, and perhaps Carditis. 

A young man, about twenty-seven years of age, 
entered the hospital Cochin, leaving that of La Cha- 
rite, where he had been treated, he said, for a ca- 
tarrhal affection of the chest. Formerly of a strong 



DISEASES OF THE PERICARDIUM, 245 

constitution and well formed, he was, at that time, 
very thin, and had a sallow and almost earthy com- 
plexion : his weakness was considerable; he still had 
dyspnoea, and the inferior limbs were infiltrated. We 
prescribed aperients, which the symptoms of abdo- 
minal irritation, after a while, obliged us to suspend. 
In the meantime the infiltration disappeared, the re- 
spiration became free; whilst the patient, whose ap- 
petite was voracious, wasted away by diarrhoea and 
abdominal pain. He died on the 20th of October, 
1823, about six weeks after entrance. 

Inspection of the Body. — The lungs rose-coloured, 
crepitant, perfectly healthy, adhered, on all sides, to 
the walls of the chest and the pericardium; the latter 
adhered to the heart at all points. There existed, 
between them, an albuminous exudation, of the con- 
sistence of the white of a boiled egg, yellowish, feebly 
united to the surface of the heart, from which we 
could tear it like any common false membrane, and 
of recent formation; but more adherent to the inter- 
nal surface of the pericardium, to which it was held 
by cellular compact filaments. The heart buried, 
and, as it were, lost in the midst of this albuminous 
mass, the walls of which were more than three lines 
thick; the heart was very small, as if it had been atro- 
phied by compression; its external surface was of a 
deep red, shaded with blackish tints: the finger, in- 
troduced into the left ventricle, filled nearly its 
whole capacity. This organ was softened, of a brown- 
ish tissue, and very easily torn. 

There was no symptom which would enable us to 
recognise, or even suspect this disease. The pa- 
tient no longer suffered; he had dyspnoea; his legs 



246 DISEASES OF THE PERICARDIUM. 

were swollen; but to how many diseases do not these 
symptoms appertain? We should think that they de- 
pended upon a fluxion of the lungs passed to the 
chronic stage. In other respects, the patient was 
not examined with sufficient care, to enable us to es- 
tablish, with certainty, any diagnosis. 

Here, however, is a case of pericarditis, compli- 
cated with pleura-pneumonia. 

Case LXVIL 

Phlegmasia of the Pericardium, and, perhaps, even of the Tex- 
ture of the Heart, Complicated with Peripneumonia. 

Claude Vedte, baker, twenty-eight years of age, 
of a sanguine temperament, was taken, while at work, 
on the morning of the 8th of December, 1812, with a 
febrile chill, soon followed with a stitch in the side, 
below and on the outside of the left mamma. The pain 
obliged him to stop working, and he returned home, 
suffering, besides the symptoms indicated, difficulty 
of respiration, dry cough, cephalalgia, lassitude, an- 
orexia, thirst and diarrhoea. The second day of the 
disease, after a rather calm night, same symptoms as 
yesterday, and, farthermore, a sense of burning below 
the trachea, especially during cough, which brought 
away viscous and tenacious sputa: impossibility of 
making a deep inspiration, and of lying on the side 
diseased. The third day, respiration very short; 
pain augments on pressure; pulse frequent, strong, 
rather hard; heat, dry, intense; mouth clammy; 
tongue slimy; no headach. (Bleeding morning and 
evening, expectorant and anodyne drink. ) Evening, 
pulse less elevated, and able to lie on the left side. — 



DISEASES OF THE PERICARDIUM. 247 

Fourth day, diminution of the pain of the side, diffi- 
cult respiration, pulse continues hard and accelerated. 
(Six grains of ipecac.) — Neither stools nor vomiting. 
— Same state as in the evening. — Fifth day, face al- 
tered; pains under the sternum, especially at the left 
side; pulse much accelerated; urine very turbid; stools 
not frequent, but very liquid; can lie on the back; no 
pain in the head or the abdomen. Slight exacerba- 
tion in the evening; in the night copious perspiration. 
Sixth day, respiration somewhat less painful, pulse 
concentrated, much accelerated; heat of the skin, 
tongue very red at the point, whitish on its superior 
surface, thirst intense, desire for aliments. Seventh 
day, the patient says he has no pain in any part, that 
he suffers only some difficulty under the sternum, 
and that he feels very weak. Eighth day, face more 
altered; delirium in the night. Ninth, the chest 
gives a rather flat sound; the pulsations of the heart 
are imperceptible, the face is discoloured, the eyes 
sunken; the pulse is weak, unequal, very irregular; 
can lie on either side. (Twelve leeches to the chest; 
blister. ) — Many evacuations in the day. In the even- 
ing, pulse intermittent, face animated, respiration 
almost stertorous, delirium in the early part of the 
night. The tenth day, sweating, towards morning 
intestinal pulse well marked; expectoration more li- 
quid, drowsiness during the day; two liquid yellow- 
ish stools. In the evening exacerbation. — Night 
more calm. The eleventh day, copious perspiration, 
sputa more mucous and more opaque. Twelfth day, 
deep pain under the sternum; urine red, pulse very 
irregular in the evening. — Thirteenth day, weakness 
and irregularity of the pulse augmented, face alters 



248 DISEASES OF THE PERICARDIUM. 

more and more; the patient much fatigued by lying 
a-bed, remained sitting up for two hours in the after- 
noon; sweating of the forehead. The fourteenth day, 
pulse slow and weak, inspiration very painful, left 
side of the chest gives, more or less, flat sound; cough 
frequent when he lies on that side. (Ten leeches, 
afterwards a blister to the side affected.) — Drowsi- 
ness, during the day. — Evening, pulse rather hard; 
desire for food. Night, loud snoring, mouth dry 
and clammy. Fifteenth day, face pale, much al- 
tered, hollowness of the cheeks, warm moisture, re- 
spiration interrupted with sobs; tongue earthy, red 
at the edges; abdomen tense, but not painful, oedema 
of the legs. — In the evening, pulse frequent, inter- 
mittent, concentrated. (Aperient and pectoral 
ptisan.) Night, sweating, and stertorous snoring. 
Sixteenth day, abdomen swollen, infiltration of the 
abdominal extremities, pulse feeble, intermittent. 
Seventeenth day, extreme prostration, pulse very 
unequal, very irregular, feeble and slow. In the 
evening, inquietude, pulse uncertain, leaping of the 
tendons; respiration very short and compressed, great 
thirst and heat, continual perspiration. — In the night 
involuntary dejections, great dryness of the mouth, 
drowsiness, with frequent watchings. Eighteenth 
day, colliquative sweats, convulsive motions of the 
aloe nasi. — Evening, pulse more equal, increased anx- 
iety, sensation of excessive heat of the whole body, 
continual difficulty below the trachea; erysipelatous 
redness of the skin; no fixed pain; intense thirst; night, 
more disturbed than the preceding. Nineteenth 
day, inspiration stertorous, sweating, rattle — death, 
in full possession of his reason, at seven o'clock in the 
evening. 



DISEASES OF THE PERICARDIUM. 249 

Inspection of the Body. — Body of a man very 
strong, five feet six inches; abdomen tense, and legs 
a little cedema.tous. — Abdomen. — Stomach and intes- 
tines untouched, distended by gas; liver yellow on 
its diaphragmatic surface, of a natural colour in the 
rest of its extent. — Chest. — Pericardium much dis- 
tended, adhering to the cartilages of the ribs and 
sternum; in the cavity of this membranous sac, a pint 
of white, opaque, albuminous fluid, of a very fetid 
odour. — The heart, floating in the midst of this li- 
quid, is covered over with albuminous concretions, 
dense, white, areolated, thickened by many lines, 
and easy to tear: the tissue of the heart is a little pale, 
and easy to break. Right lung depressed, evidently 
hepatised, of a reddish-brown, floating in half a pint 
of reddish turbid serum. Same liquid in the left 
side: corresponding lung hepatised, adhering to the 
diaphragm by some albuminous columns. 

This case, stated with great precision, is distin- 
guished from the preceding by a remarkable circum- 
stance: the pulse was strong and hard at the com- 
mencement, whilst, in the simple pericarditis, it is 
small, contracted, and convulsive; but do not forget 
that the phlegmasia, in the present case, had first 
seized upon the lung to be afterwards propagated to 
the pericardium, and, perhaps, to the heart itself; 
then the pulse is, in fact, concentrated, and two days 
after the inflammation, tending to a fatal termination, 
we observe this insidious remission, so frequent in the 
phlegmasia of the serous-membranes. 

If we take a rapid view of the preceding observa- 
tions, we shall see that the principal symptoms which 

32 



250 DISEASES OF THE PERICARDII!!*. 

characterize them, are, sharp, tearing, acute and 
pungent pain, dyspnoea and extreme anxiety, conti- 
nual jactitation, small, contracted, frequent, convul- 
sive pulse, contracted state of the face, with agita- 
tion, and even convulsive spasm of some of its mus- 
cles, and particularly of those which, receive branches 
from the nerves, designated, in these latter times, by 
the name of respiratory nerves of the face; perfect 
inability of straitening and extending the body, which 
is bent forward; lastly, symptoms which announce an 
obstacle to the circulation, such as infiltration of the 
limbs, violent injection of the cheeks and lips: high 
fever, with burning dryness of the skin, accompany- 
ing the preceding symptoms, and complicated, some- 
times, with delirium, more or less, developed. This 
collection of symptoms denotes, with tolerable cer- 
tainty, a phlegmasia of the thoracic viscera; but se- 
veral of them are common to pleurisy, to pleuropneu- 
monia and pericarditis. Which are those, which 
specify the last? It seems to u<*, that these consist 
in a continual tendency to hypothymia, and jactita- 
tion; contracted, small,, convulsive pube; pain in the 
precordial region, with impossibility of maintaining 
the horizontal posture;, in every instance we dare not 
affirm but that a pleurisy of the whole left pleura ex- 
ists to produce the same phenomena. It is, there- 
fore, impossible, from these symptoms, to trace the 
distinctive characters of these two diseases; the only 
mode, according to us, of avoiding all mistakes on 
this point, is to practise auscultation and percussion; 
but, in order to avoid superfluous repetitions, we shall 
not speak here of the differential signs furnished by 



DISEASES OF THE PERICARDIUM. 251 

this method of exploration, and we shall refer the 
reader to what we have to say of the diagnosis of 
acute pericarditis. 

We shall proceed to show the anatomical altera- 
tions, which characterize pericarditis in its first stage; 
it remains for us to examine, at present, what are 
those met with, when individuals do not die at this 
period. If we recollect the various changes which 
the matters, secreted by inflamed serous membranes, 
undergo, we shall readily be able to foresee those, 
which take place in those albuminous masses, and 
those false membranes, of more or less thickness, 
which we find in the pericardium when affected with 
inflammation. In fact, analogy informs us that this 
inflammatory production, endowed with a tendency 
to become organized? will become gradually thick- 
ened, permeated with red vessels, and transformed 
into cellular tissue, or even fibrous, fibrocartilagi- 
nous, cartilaginous, or, it may be, osseous membrane. 
That which analogy leads us to foresee, observation, 
the source of all truth in medicine, fully confirms, as 
we shall have occasion to demonstrate in the following 
facts relative to chronic pericarditis. 



252 DISEASES OF THE PERICARDIUM. 

SECTION II. 

CASES OF CHRONIC PERICARDITIS. 
Case LXVIII. 

Chronic Pericarditis, with Cellular Adhesion of the Pericardium 
to the Heart, without Complication. 

Jean Brousse, water-carrier, fifty-one years of age, 
of a sanguine temperament, was admitted to the hos- 
pital Cochin on the 20th of March, 1812. He had 
suffered for fifteen years, palpitations and difficulty of 
respiration, which had gradually increased; the hori- 
zontal position produced oppression and insupporta- 
ble suffocation; he frequently awoke suddenly; the 
abdominal extremities were (Edematous: all these 
symptoms were augmented for about a year, and, at 
the time of entering the hospital, the thoracic extre- 
mities were infiltrated: the extremities were fre- 
quently cold; the abdomen was voluminous, the com- 
plexion appeared of a deep red, the lips were livid, 
and the pulse almost imperceptible; the beatings of 
the heart offered some irregularity and intermittence, 
and it appeared that this organ suffered some obstacle 
to its motions. The precordial region gave an ob- 
scure sound; lying on the back was impossible; a fre- 
quent and rather violent cough, was followed by an 
expectoration of thick yellow sputa. Death super- 
vened eighteen days after he entered the hospital. 

Inspection of the Body. — The lungs were healthy, 
the pericardium adhered very closely to the whole 
surface of the heart: the texture of which was soft- 



DISEASES OF THE PERICARDIUM. 253 

ened, a little thickened, and, perhaps, dilated. The 
chest did not contain serum. All the other viscera 
were healthy. 

This is a rare example of pure and simple adhesion 
of the pericardium to the heart, which sent the pa- 
tient to the grave. The general symptoms were very 
similar to those observed in most diseases of the heart, 
so that we could not obtain sufficient light to establish 
the diagnosis of these affections, or sufficient means to 
distinguish them from each other. Nevertheless, 
there is one symptom in this case which should not 
be overlooked, and that is the impediment which the 
heart seemed to sustain in its motions, as if the adhe- 
sions alluded to had produced some restraint. 

. Case LXIX. 

Fibro-Cartilaginous, and somewhat Lardaceous Adhesion of the 
Pericardium of the Heart, fyc. 

Claude Prieur, aged 19, baker, of a lymphatic 
temperament, was admitted to the hospital Cochin 
the 7th of February, 1821. He was, at that time, 
pffected with a scrofulous swelling of the great toe, and, 
soon after, the progress of the disease made it neces- 
sary to amputate this part; the consecutive wound 
cicatrized. In the mean time ulceration, kept up 
by the carious bones of the foot, soon appeared in 
different points of the skin; to this was added swell- 
ing, with suppuration of the inguinal glands of the 
right side; the abdomen became swollen and painful : 
we observed, from time to time, a little looseness, 
cough, and hectic fever, with exacerbation in the 
evening: the pulsations of the heart and the pulse 



254 DISEASES OF THE PERICARDIUM. 

were regular, frequent, and of moderate force. AH 
the means of relief were unavailing, and the patient, 
exhausted by a slow fever, died, in the last stage of 
marasmus, on the 8th of July, 1822, seventeen months 
after entrance. 

Inspection of the Body, twenty four Hours after Death. 

The bones of the metatarsus were carious; the 
right inguinal glands* formed a tubercular mass, 
partly friable, and partly hard like cheese, and even 
like a half boiled chesnut. All the ganglions of the 
abdomen, of the mesentery, and the bronchi, pre- 
sented a similar disorganization. 

The Abdominal Cavity contains a large quantity of 
citrine-coloured serum : it is, as it were, separated into 
two distinct cavities, by the arch of the colon adhering 
to the anterior wall of the abdomen, and the neigh- 
bouring parts. The peritoneum, in the whole of its 
extent, offers a remarkable alteration, difficult to de- 
scribe; it is strewed with granulations, smaller and 
more numerous, on the portion which covers the pa- 
rietes, larger and more projecting on the viscera, 
where they are of a yellowish white, friable, about 
the size of a hemp-seed, and of a tubercular nature : 
the surface, from whence they arise, has some resem- 
blance to the skin covered with confluent small-pox. 
The peritoneum, which appears thickened, is de- 
tached with great facility from the other intestinal 
membranes; and we find, by this means, its adhering 
surface perfectly united. The confluent granulations, 

* There was no infiltration of tht body: thr crural vrssrls «TCW p«rfe< 
healthy. 



DISEASES OF THE PERICARDIUM. 25> 

with which the parietal fold is, for the most part, 
covered, are of a whitish colour, mixed with red, sur- 
rounded with injected vessels, giving to the perito- 
neum the appearance of granite, which, besides the f 
colours indicated, has a shade of bluish black. * This 
portion of the serous membrane is thicker than that 
which covers the intestines; it is of a fibrous consist- 
ence, and about half a line thick. The stomach, 
rose-coloured on the interior, is small, contracted, 
and almost hidden behind the liver and the transverse 
arch of the colon. The small intestine, in the whole 
of its course, is completely healthy; the mucous mem- 
brane of the large intestine is generally white, and 
entirely exempt from ulceration; this intestine con- 
tains solid foecal matter. The liver adheres to the 
anterior surface of the abdomen by a false membrane 
almost fibrous. — The fibrous membrane of the spleen 
is much thickened. The bladder, distended by an 
enormous quantity of urine, has its mucous membrane 
perfectly white, whilst its serous membrane presents 
the granular alteration spoken of in its full intensity. 
Cavity of the Chest. — In the right side, the pul- 
monary, costal, diaphragmatic, and pericardiac plursB 
adhere to each other very closely, especially in the 
diaphragmatic region; several tubercles are met with 
behind the sternum. The left side contains a large 
quantity of citrine-coloured serum; the pericardium is 
disseminated with small, friable miliary granulations, 
somewhat resembling, at first sight, small syphilitic 
vegetations. The rest of the cavity of this membrane 
is wanting : the corresponding surfaces of the, peri- 

* This colour is owing to small melanic masses, 



256 DISEASES OF THE PERICARDIUM. 

cardium adhere to each other by a compact cellular 
production. The portion which covers the heart, 
for the most part about a line thick, is much thicker 
on the posterior part of the organ; it grates under 
the knife; and such is its hardness that, to the touch, 
the heart is of a scirrhous consistence, especially at 
the back part. The walls of the two ventricles are 
thickened; the texture of their anterior part, firm 
and red coloured, differs materially from that of their 
posterior portion, which is less distinctly fibrous and 
fleshy, as if it had begun to partake of the lardacious 
disorganization of the pericardium. The lungs did 
not contain a single tubercle in their interior; they 
are perfectly crepitant: a single softened tubercle ex- 
isted on the surface of the right. The bronchial 
ganglions, partly black, and partly whitish yellow, 
formed hard or already softened masses, as has been 
noticed above; the mucous membrane of the bronchi 
is rose coloured. 

Cavity of the Cranium. — The brain has little con- 
sistence; the meninges are healthy; there exists a lit- 
tle serum at the base of the cranium and the cerebral 
ventricles. 

Case LXX. 

Carcinomatous Tumour in the Anterior Mediastinum — Indura- 
tion of the Pericardium — Phlegmasia of the Pleura and 
Aorta. 

The patient, named B , 33 years of age, shoe- 
maker, rather firmly constituted, formerly a soldier, 
had been affected with venereal disease, for which 
he had taken mercury, was admitted, the 25th of 
December, 1820, to the wards of the hospital Cochin, 



DISEASES OF THE PERICARDIUM, # 257 

having, behind the sternum, a tumour which he at- 
tributed the formation of to the nature of his occu- 
pation, which obliged him to make almost continual 
exertions, during which the sternal region was sup- 
ported strongly against solid bodies, such as shoe lasts, 
&c. It was in 1814 that this tumour began to be de- 
veloped, or, rather, that the patient suffered pains 
under the sternum so violent that he was obliged to 
abandon his occupation; his respiration became much 
embarrassed, and, on the least exertion, he became 
suffocated and faint. A physician, whom he con- 
sulted last year, applied some leeches, and a blister, 
behind the shoulders, and recommended frequent 
bleedings: these means relieved him. Neverthe- 
less, towards the end of October, that year, he per- 
ceived that he had a pulsating tumour in the region 
of the sternum. His condition, on entering the hos- 
pital, was as follows : face pale, lips violet red, eyes 
dull and spiritless, dyspnoea; pulse small, rather re- 
gular, sleep very short, interrupted by frightful 
dreams; cough violent, followed by mucous sputa. — 
The pulsations of the substernal tumour, isochronous 
with those of the pulse, and tumultuous, seemed to 
be heard in almost the whole anterior part of the 
chest; pressure was painful, and occasioned the ster- 
num to yield; the skin which covered the tumour 
had not changed colour, but was warmer than the re- 
maining parts. 

The day after his arrival, he complained of a stitch 
in the side, which he then felt for the first time: it 
corresponded to the posterior, lateral, right part of 
the chest, and was opposed by bleeding, which pro- 
duced momentary relief, but it quickly reappeared, 

33 



258 DISEASES OF THE pericardium, 

and with even increased violence, on the following' 
days, The patient had been in the hospital more 
than twenty days, when there suddenly supervened, 
in the night of the 14th of January, a trembling, 
which lasted about an hour, with cold sweats, op- 
pression, fainting, and painful cough: the pulse had 
become small, frequent and irregular; the pulsations 
of the tumour, much less sensible, seemed to have 
augmented in extent; the face was dull, and cadave- 
rous; the lips blue, and the thirst intense. 

We were fearful of the rupture of an aneurismal 
tumour, and, consequently, the immediate death of 
the individual. Nevertheless, he was decidedly bet- 
ter the next day, his respiration becoming less em- 
barrassed. But he incessantly complained of a paii* 
in the side, which obliged him constantly to retain 
the same position. Leeches were applied to the part 
affected, which procured relief. It is remarkable, 
that there appeared, near the painful part, a tumour; 
which, in its progress, invaded the arm, forearm, and 
hand. The skin was quite tense. In the mean time, 
the symptoms became daily more alarming; and the 
patient, perfectly sensible of his situation, died on 
the 22d of January, about noon. 

Inspection of the Body. — The sternum, and the 
cartilages of the true ribs, altered and softened, 
formed a portion of a lardacious, carcinomatous tu- 
mour, developed between the lam in s& of the medias- 
tinum, which it had affected throughout; so that not 
the least trace of it could be discovered. The peri- 
cardium itself, confounded with the tumour, which 
was remarkably thickened, adhered to the heart in 
its whole extent; the inferior part of the left pleura 



DISEASES OF THE PERICARDIUM, 259 

was covered with a sero- purulent, whitish lamina; 
the portion of the lung in contact with the pericar- 
dium, altered in its texture, seemed to participate in 
the disease of the mediastinum; the left cavity of the 
chest, at its lower part, was the seat of a purulent 
effusion. 

The heart had increased in volume; its right ca- 
vities were dilated; the walls of the left ventricle, the 
cavity of which was contracted, were thickened about 
an inch; the valves and columns offered nothing pe- 
culiar; the cellular membrane, which united the sur- 
face of the heart to the pericardium, was infiltrated. 
The aorta, externally, was perfectly healthy; its in- 
ternal membrane offered, in many points, a deep red, 
which extended as far as the iliacs in one direction, 
and, in the other, as far as the axillary and external 
and internal carotids of each side : at the same time, 
the membrane appeared thickened, and easily sepa- 
rated from the middle membrane. The pulmonary 
artery appeared to be straightened, and its internal 
membrane was without redness. The abdominal or- 
gans were healthy. 

Case LXXI. 

Partial Ossifications and Adhesions of the Pericardium. — 
Peritonitis. 

A commissioner, fifty-eight years of age, was af- 
fected with constant dyspnoea for eight years; and, 
whenever he went up stairs, or took more than ordi- 
nary exercise, was suddenly affected with suffoca- 
tion, and obliged to stop. The face was swollen, 
and livid, the lips were of a violet colour: the pulse 



260 DISEASES OF THE PERICARDIUM. 

small, frequent, irregular, and sometimes intermittent. 
We perceived a peculiar rushing murmur in the re- 
gion of the heart. These symptoms, having been 
slowly developed, produced but little disquietude in 
the patient, who would take no medicine for his re- 
lief. In the mean time the disease continued to ad- 
vance, and the legs began to be (Edematous, which 
determined the patient to enter the hospital Cochin. 
To these phenomena may be added a flat sound, in 
the whole left side of the chest: the patient, farther- 
more, suffered, at intervals, increased intensity of 
the symptoms, or a kind of paroxysm, during which 
there was impending suffocation. The urine was di- 
minished in quantity, and had a red sediment. We 
merely employed diuretics to remove the oedema 
and serous effusion, which the flat sound seemed to 
denote. The infiltration having been removed, and 
the sound having become sufficiently clear in the su- 
perior part of the chest, the patient believed him- 
self able to leave the hospital; but a renewal of the 
symptoms quickly induced him to return, and he was 
again relieved by aperients. Two years were passed 
in this doubtful state; three months seldom elapsing 
without witnessing the patient's return to the hospi- 
tal for assistance. In addition to the symptoms above 
mentioned, he was sometimes affected with pulmona- 
ry catarrh. His constitution, in the mean time, be- 
came every day weaker, and he entered the hospital, 
for the last time, on the 18th of August, 1809. The 
symptoms, collectively, were no longer the same: 
the body lost its fulness, and the livid appearance, 
and assumed the characters which announce painful 
chronic affections of the abdomen. The complexion 



DISEASES OF THE PERICARDIUM. 261 

Was yellow, and of a leaden hue; the cheeks sunken; 
the eyes dull; the features sharpened; the pulse re- 
tained its smallness and irregularity, but was weaker 
and softer; the dyspnoea was less violent; the thorax 
gave a clear sound in the whole of its extent : we 
could hardly perceive the beatings of the heart : the 
abdomen was tense, painful throughout, and seemed 
to contain a large quantity of fluid. There was con- 
stipation. Tonics, with aperients, formed the basis 
of the treatment, but no relief was obtained from 
them. Several days previously to death, which oc- 
curred on the 2d of September, delirium and diar- 
rhoea supervened, with total loss of expression. 

Inspection of the Body. — The head presented no- 
thing peculiar. 

There was no serum in the chest; the lungs were 
healthy; externally, the pericardium had contracted 
close adhesions with the left lung, and internally 
with the surface of the heart; it presented numerous 
ossifications, which had their seat between the serous 
and fibrous membrane on the one side, and the heart 
on the other. One of the most considerable of these 
ossifications, terminating in a point towards the apex 
of the heart, had perforated the pericardium, and 
given rise to the formation of a purulent deposite, of 
considerable extent, on the superior surface of the 
diaphragm. We observed another circular ossifica- 
tion, which formed a sort of coronet to the right au- 
ricle, situated between its texture and the serous 
fold which borders it. The heart was natural, ex- 
cepting that its fibres were livid and flabby. 

The peritoneum exhibited evident traces of phleg- 
masia. Masses of false membrane were observed 



262 DISEASES OF THE PERICARDIUM. 

uniting together the viscera of the abdomen, the dia- 
phragm and the abdominal parietes. After removing, 
with some difficulty, these numerous adhesions, we ob- 
served the internal circumvolutions united, anterior- 
ly, in a kind of globe: here and there were immense 
abscesses, not communicating with each other, but 
containing, each of them, a grayish liquid. We shall 
not insist, here, on the coincidence between perito- 
nitis and pericarditis: medical men have but too 
frequently had occasion to remark the facility with 
which the several divisions of the serous system com- 
municate their diseases to each other. It is not un- 
common to observe inflammation of the pleura, peri- 
cardium, peritoneum, and even the arachnoid mem- 
brane, affected at the same time. There is nothing 
in this coincidence which ought to surprise us; the 
various dependancies of the same tissue ought, in 
fact, to present the same relations and the same sym- 
pathies in disease which are observed in health. It 
has also been observed, that diseases, instead of dis- 
turbing the operations of the laws of sympathies, or 
rather instead of weakening their empire, give them 
new force and intensity : and, indeed, bring to light 
many sympathies, which, without their intervention, 
would probably never have been discovered. 



DISEASES OF THE PERICARDIUM. 263 



ARTICLE II. 

GENERAL HISTORY OF PERICARDITIS, 
SECTION I. 

ANATOMICAL CHARACTERS OF PERICARDITIS, 

We shall treat successively, in this chapter, of pe- 
ricarditis, and the matter which it secretes when in 
a state of more or less acute inflammation. The red 
and injected state of the pericardium indicates phleg- 
masia: thickening rarely takes place, or is but slight- 
ly marked. When it does occur, it may, most com- 
monly, be attributed to a thickening produced by 
the organized false membranes, which closely adhere 
to the pericardium: the red colour is seldom general. 
but is more frequently limited; the membrane is some- 
times strewed with numerous red points in groups, 
which give it a speckled or dotted appearance: at 
other times, speckled plicae are observed, of more or 
less extent, and more or less numerous: the injected 
state is generally proportionate to the redness. In 
some cases, however, it may be said that the red co- 
lour is uniform, resembling a species of tincture, 
and is independent of vascular injection. 

Sub-acute pericarditis is said to have been ob- 
served with hardly any trace either of redness or 
injection; but more or less intense injection and de- 
velopment of reticulated vessels, have been constant- 
ly observed in chronic pericarditis. 

The matter secreted by the pericardium in a state 
of inflammation consists of two parts; the one con- 



264 DISEASES OF THE PERICAKDIUM. 

crete, the other liquid: the portion which is con- 
crete constitutes the false membranes. The concrete 
and the liquid portion exist in extremely variable 
proportions, according to the degree of inflamma- 
tion, and, undoubtedly, according to other circum- 
stances as yet but little known. The liquid, or serous 
portion, ordinarily mixed with albuminous flocculi, 
is turbid, rarely entirely limpid, of a citrine-green- 
ish, reddish brown, or lactescent colour; sometimes 
the fluid appears curdled. The quantity may amount 
to several pounds. At other times the quantity is 
very small, and the concrete matter extremely abun- 
dant, with scarcely any serum. In those cases where 
it is found in very large quantity, the pericardium 
is much distended, and forms an immense fluctuating 
pouch. 

The false membranes of an albuminous nature, the 
moment they are exhaled, are formed into amorphous 
masses of various sizes, which afterwards enlarge, 
and extend over the surface of the pericardium, so 
as either wholly or partially to cover it, and thus re- 
ciprocally unite its corresponding portions. They 
frequently form, also, successive layers; and their 
surface is sometimes unequal and rough. At other 
times they form alveolar depressions, or separate 
cells, resembling pieces of sponge. These are, pro- 
bably, the analogous false membranes, the external 
arrangement of which Corvisart compares to the in- 
ternal surface of the reticulum, or second stomach of 
the calf.* 

* See page 19, of his work, 3rd edition. In the seventy-fifth case, the 
pseudo-membranous concretions resembled fungous vegetations; and some 
of them were cut in the form of a cock's comb. 



DISEASES OF THE PERICARDIUSl. 265 

Iti some cases the false membrane is so intimately 
combined with the serum, that the fluid resulting 
from the mixture appears to be wholly purulent. 
Should the pericarditis pass into the chronic state, 
and a cure be effected, the false membrane passes 
through a series of changes, which we shall present- 
ly notice. 

Absorption gradually invades all that is suscepti- 
ble of being removed by it, and the portion which 
remains becomes thickened, and unites or aggluti- 
nates the contiguous surfaces of the membranes. 
Meanwhile, red points and lines, and afterwards re- 
ticulated vascular patches appear in these accidental 
productions, which are soon converted into serous 
laminae, or cellular tissue, which afterw r ards form the 
general or partial adhesions of the pericardium. 

The adhesion may be more or less close and com- 
pact: sometimes it is difficult to separate it, except 
by a cutting instrument. Similar adhesions have led 
to the belief that the pericardium was deficient. It 
was only in the infancy of the art that the laminae, or 
cellular filaments uniting together, that a portion of 
the serous membrane covering the heart, and that 
reflected on its fibrous envelope, were mistaken for 
hair. 

The substance of false membrane may not only be 
converted into cellular tissue, but we have seen it 
organized in the form of fibrocartilaginous, cartila- 
ginous, and even osseous tissue, of which we have 
already given several examples. These accidental 
tissues may exist, in greater or less quantity, and 
may even exist with adhesions purely cellular. 

At other times, we find nothing more than white 

34 



266 DISEASES OF THE PERICARDIUM* 

or milky plicae on the surface of the heart. They 
vary in form and extent, and, in general, are easily 
detached. They are rarely very thick. The peri- 
cardium, below them, is injected without being thick- 
ened. The whitish spots are traces of partial peri- 
carditis. 

Finally, in other cases, the exuded organized mat- 
ter forms small masses, which become organized into 
vegetations of a rounded form, or even tubercular 
granulations. These tubercles, disseminated on the 
surface of the heart, break down like boiled albumen, 
are easily detached, and resemble certain vegetations, 
or pustules of the valves. 

The muscular substance of the heart often remains 
perfectly free from disease; at other times we find it 
redder or brown, pale, yellow, softened, and easily 
torn. In these cases, it appears to have participated 
in the inflammation. 

In some cases the effusion produces the same effect 
on the heart, which it commonly does on the lungs; 
that isj compresses, diminishes, or atrophies it. 



1L—OF THE SYMPTOMS AND DIAGNOSIS OF 
PERICARDITIS. 



SECTION I. 

SYMPTOMS OF ACUTE PERICARDITIS. 

The diagnosis of acute pericarditis is rather diffi- 
cult : this seems to depend upon the circumstance 



DISEASES OF THE PERICARDIUM. 267 

that it is always complicated with some other thora- 
cic phlegmasia, or on the fact that its symptoms are 
sometimes scarcely to be observed. The symptoms 
which w T e have noticed are the following: Fever, 
more or less intense, with a dry skin; sharp, acute, 
lancinating pain in the precordial region; sensation 
of burning heat in the same situation; incapability of 
straightening the corresponding side of the chest, 
and of lying in the horizontal position; irregular and 
feeble contractions of the heart; very great anxiety, 
with distortion of features; swooning; continual jac- 
titation, with terror and despair; small, frequent, 
contracted, unequal, irregular, intermittent and al- 
most convulsive pulse; dyspnoea; cold sweat at inter- 
vals, and, at a later period, phenomena which an- 
nounce an obstacle to the circulation, such as lividity, 
swelling, injection of the face, and oedema of the 
limbs. 

But we do not observe, in every case of pericar- 
ditis, all the phenomena we have mentioned. When 
this is the case, the physician ought to redouble his 
attention, to enable him to form a diagnosis founded 
on the number of symptoms which remain. 

The disease which may most easily be confounded 
with pericarditis is pleurisy. There is, however, a 
characteristic sign which enables us to distinguish it; 
namely, egophony : this phenomenon is never ob- 
served in pericarditis; it is peculiar to pleurisy. 

If, in all cases, we were to confound acute pericar- 
ditis with pleurisy, the error would be of little con- 
sequence, the treatment of both diseases being essen- 
tially the same. 

As yet auscultation has not furnished any sign by 



268 DISEASES OF THE PERICARDIUM. 

which we can recognise acute pericarditis, unless we 
choose to consider as such the sound of new leather, 
noticed by M. Collin, author of a treatise on the dif- 
ferent methods of exploring the chest. 



SECTION II; 

SYMPTOMS AND DIAGNOSIS OF CHRONIC PERICARDITIS. 

The symptoms of chronic pericarditis are much 
more obscure than those of acute pericarditis. " Not 
unfrequently," says M. Laennec, "1 have found 
the pericardium full of pus, in fact, in a state of chro- 
nic inflammation, without any thing to lead me to sus- 
pect such an affection in these subjects."* " I have 
not unfrequently met with this disease, and I have 
always found the diagnosis difficult, and sometimes 
even obscure," says Corvisart.f The symptoms of 
chronic pericarditis, are, for the most part, the same 
as those of the acute, excepting that they are some- 
what less distinct. Lastly, when the disease termi- 
nates by adhesion, by the formation of adventitious 
membranes of cartilage or bone, it may happen that 
such a termination does not give rise to any disturb- 
ance of function, and then it is quite impossible to 
form any diagnosis; or even that the same termina- 
tion develops symptoms which announce an embar- 
rassment of the circulation, and then the physician 

* De PAuscult. torn. ii. page 392. 

\ Essai sur les Maladies du Cccur, page 30, 3d edit. 



BISEASES OF THE PERICARDIUM, 269 

will make every effort to endeavour to determine the 
cause to which he ought to refer the disturbance of 
the circulation; and, notwithstanding all his endea- 
vours, if he cannot arrive at it, he will act according 
to the indications furnished by the symptoms. 

We shall here speak of a new symptom, by means 
of which Dr. Sander has been enabled to ascertain 
the adhesion of the pericardium to the heart : it con- 
sists of a long-continued, strong, undulatory move- 
ment, to be discovered lower down than that or- 
dinarily discovered in the region of the heart. M. 
Sander has explained this kind of motion as follows: 
" During the simultaneous contraction of the ven- 
tricles the apex of the heart is carried upward in 
front, toward the fifth rib; and, consequently, draws 
upward the inferior portion of the pericardium with 
the diaphragm, and every thing adhering to it : at 
the same time, a depression under the left ribs of the 
superior region of the abdomen is obstructed. Im- 
mediately afterwards, the ventricles relaxing dilate 
to receive the blood, the apex of the heart moving 
suddenly downward; and, not having free space to 
move in, communicates to the adhering pericardium, 
the diaphragm, and other parts, the shock, which 
becomes sensible, exteriorly, by a slight elevation, 
discovered in the situation where but a moment be- 
fore the depression had formed, but which, however, 
extends a little lower down. Strictly speaking, the 
depression precedes the shock; since the contraction 
of the auricles is the commencement of the action of 
the heart. Thus," adds Dr. Sander, " notwithstand- 
ing what Corvisart has said, there exists a mechani- 
cal sign which will never deceive, which enables us 



270 DISEASES OF THE PERICARDIUM. 

to recognise with great facility adhesions of the pe- 
ricardium, even when they are complicated with 
other diseases of the heart or the chest. 



Ill— OF THE CAUSES OF PERICARDITIS. 

The causes of this phlegmasia are evidently those 
common to the other phlegmasia in general; blows, 
falls on the precordial region, immoderate exercise, 
suppression of transpiration, such as usually takes place 
on exposure to the air while in a state of perspira- 
tion, imprudent use of cold drinks in similar circum- 
stances, abuse of irritating ingesta, retrocession of 
exanthems, rheumatic or gouty afFections, &c. These 
causes will be so much the more efficient, in propor- 
tion as they act on individuals of a robust, sanguine, 
and, at the same time, irritable temperament. 



IV.— PROGNOSIS. 

Sub-acute pericarditis is a disease of extreme se- 
verity, taking into view the importance of the func- 
tions of the organ whose envelope is affected. Ne- 
vertheless, we ought not to regard it, with Corvisart, 
as necessarily mortal : it may yield to bleeding, pro- 
perly directed. Sub-acute, or chronic pericarditis, 
is not so immediately dangerous : in every instance, 
it may involve the most disastrous consequences, if 
the treatment be neglected, or improperly managed. 

What shall we here say of the danger which may 



DISEASES OF THE PERICARDIUM. 271 

result from the various accidental tissues which may 
be produced by pericarditis? What is there which 
has not been written on the adhesion of the pericar- 
dium? Some have regarded it as a source of severe 
accidents; others have adopted the contrary opinion. 
Morgagni has discussed, at length, the question whe- 
ther this adhesion determines palpitations. It would 
appear, at first sight, that such a lesion would dis- 
turb the regular motions of the diaphragm; and that, 
on the contrary, the contractions of the diaphragm 
would disturb the motions of the heart. Perhaps 
these effects actually occur in some instances; but it 
is also very certain that we find adhesions of the pe- 
ricardium complete in some individuals, in whom the 
circulation and respiration had not sustained the least 
embarrassment. It is, at least, sufficient that we are 
apprized of the extreme danger which some of them 
have attributed to it. 



V.— TREATMENT OF PERICARDITIS. 

The treatment consists in the employment of anti- 
phlogistics, in the first rank of which we place bleed- 
ing. General and local bleeding may be useful : gene- 
ral bleeding, in cases of powerful reaction, promotes 
effectually the action of local bleeding, which it ought 
to precede. We can seldom fix on the quantity of 
blood necessary to be taken : this will depend on the 
intensity of the disease, the age, strength, and sex of 
the subject. In general, we should not hesitate to 
apply a large number of leeches at once; and repeat 
the application, should it be necessary. In an adult, 



272 DISEASES OF THE PERICARDIUM. 

we may employ at once thirty, or even forty. The 
effect of the bleeding should be favoured by the most 
rigorous diet, diluent, refreshing, and demulcent 
drinks, and perfect rest. 

When the phlegmasia occurs under a slow, inac- 
tive, and chronic form, we should recur to the use 
of revellents and exutories; such as blisters, caute- 
ries, setons, and even moxas : in short, we should ne- 
glect none of those means which are appropriate in 
other inflammations. 



DISEASES OF THE PERICARDIUM. 273 



CHAPTER II. 



OF HYDRO AND PNEUMO-PERICARDITIS, 

These two affections are less frequently true dis- 
eases than symptoms of some other disease, either of 
the heart, or of the lungs. Since the more exact 
researches on the inflammations have taught us the 
connexions which exist between them and the effu- 
sions of the serous membranes, we find but very few 
idiopathic dropsies. We cannot, however, deny their 
existence. We shall begin by relating two cases of 
this kind, relative to dropsy of the pericardium: we 
' shall afterwards give a general history of this affec- 
tion. 



I— PARTICULAR CASES, 
Case LXXII. 

Idiopathic Hydro-Pericarditis ■, or, Hydro-Pericarditis without 
any Organic Lesion. 

A washerwoman, named Laroche, twenty-five years 
of age, was admitted into the hospital Cochin the 20th 
of September, 1810. She had suffered, for four 
months, great difficulty of respiration, violent pulsa- 
tions of the heart, and giddiness : the pulse was fre- 

35 



274 DISEASES OF THE PERICARDIUM. 

quent; slight accession of fever appeared at night,* 
symptoms of gastric embarrassment occurred in con- 
nexion with that state from the time she entered the 
hospital. This disease, which at first presented no- 
thing very alarming, suddenly assumed a very severe 
character, and the woman died three days after ad- 
mission. 

On opening the body, we found about sixteen 
ounces of citrine-coloured serum in the pericardium. 
The heart, and all the other viscera, were in their 
natural state. 

Case LXXIIL 

Hydro-Pericarditis, without Organic Lesion. 

Mousanas, aged nineteen years, having enjoyed 
but feeble health, had perceived, that, for six weeks 
past, without any known cause, his legs had swelled 
from day to day. Having entered the Cochin hos- 
pital, the 11th of July, 1809, he presented the fol- 
lowing symptoms : — Face pale and swollen; skin hot 
and dry; urine small in quantity; respiration tolera- 
bly free; fiat sound in the right side of the chest; 
pulsations of the heart frequent, and observed through 
a great extent; pulse small, quick, and frequent; the 
patient had altered in appearance, but retained some 
appetite. Notwithstanding the application of leeches 
to the anus, aperients and anodynes, the patient grew 
weaker every day, and died on the 23d of the same 
month. 

The pericardium contained about a pound and a 
half of clear serum; the heart was in the natural state. 
The right lung adhered, in the whole of its extent, 
with the pleura costalis. All the other viscera were 



DISEASES OF THE PERICARDIUM. 275 

healthy. We could not justly attribute death, in 
these cases, to any thing else than hydro-pericarditis. 
There is no mention made of any other lesion which 
could have produced such a fatal termination. Ex- 
amples of such simple forms of hydro-pericarditis 
must be exceedingly rare. 



IL— GENERAL HISTORY OF HYDRO -PERICARDI- 
TIS AND PNEUMO-PERICARDI7IS. 



SECTION I. 

The effusion of a more or less considerable quanti- 
ty of serum into the pericardium, constitutes hydro- 
pericarditis. It is seldom that this species of dropsy 
is primitive: most frequently, it is a consequence of 
some obstacle to the circulation; but whether it be 
primitive or consecutive, we should be very careful 
not to confound it w r ith the effusion produced by pe- 
ricarditis. 

SECTION II. 

The serum effused into the pericardium varies in 
quantity, colour, and also, perhaps, in the chemical 
elements of which it is composed. ' Sometimes we 
only find a few ounces of fluid; at other times, seve- 
ral pounds. Corvisart speaks of a case of hydro-peri- 
carditis, in which there were eight pounds of fluid :* 
the cases of this kind are not very common. The 
fluid is sometimes entirely colourless, and perfectly 

* Onv. cit. pagfff S3, 



276 DISEASES OF THE PERICARDIUM. 

limpid: at other times, it is more or less coloured, 
greenish or yellowish, and rendered slightly turbid 
by flocculi or membranous fragments, analagous to 
spiders' web, floating in the midst of it. It resem- 
bles, in some cases, a beautiful solution of the salts of 
gold. 

Sometimes, instead of a liquid purely serous, we 
meet with a fluid mixed with a certain quantity of 
blood, red, or even black. 

The pericardium does not offer any alteration, ex- 
cepting that it is distended in proportion to the quan- 
tity of liquid w r hich it contains. It seems that it is 
whiter than in the natural state, as if it had been 
washed, as it were, by the serum in the midst of 
which it floats. This white colour is more particu- 
larly noticed on the heart: as to the texture itself, it 
is perfectly healthy. We may conceive, that a very 
considerable effusion might at length compress the 
heart, diminish or even atrophy its substance. 

It is not uncommon to meet with a certain quanti- 
ty of air in the pericardium : hence, we have given 
to this disease the name of pneumo-pericarditis. The 
quantity varies much; its chemical properties are, as 
yet, unknown : it escapes with a slight hissing sound, 
when we cut into the pericardium. Pneumo-peri- 
carditis exists, ordinarily, in connexion with hydro- 
pericarditis. It may, however, be barely possible 
that the pericardium contains only a certain quantity 
of air. 

We will remark, before terminating what concerns 
the anatomy of hydro-pericarditis, that we should not 
regard as true cases of hydro-pericarditis, all the se- 
rous effusions which we meet with in the pericardii 



DISEASES OF THE PERICARDIUM, 277 

urn. It is very uncommon, on opening subjects, not 
to find a certain quantity of serum in the pericardi- 
um. That hydro-pericarditis should really exist, it 
is necessary that the quantity of liquid should be at 
least six or seven ounces :* when the quantity effused 
is less than that, for example only a few spoonsful, it 
is extremely probable that the fluid has been effused 
in the last moments of life, and that the effusion was 
the effect of the agony. 

SECTION III. 

The symptoms of hydro-pericarditis have been, for 
a long time, the subject of discussion among physi- 
cians. The symptoms which some of them have re- 
garded as pathognomonic, are scarcely worthy, ac- 
cording to the judicious remark of Morgagni, of even 
being mentioned among the equivocal symptoms of 
that disease. Lancisi, and several others, reckon 
among the most certain signs of hydro-pericarditis, 
the sense of great weight in the region of the heart. 
Reimann and Saxonia say, that the patients feel as if 
their hearts were inundated with water. Senac has 
observed, in the intervals between the third, fourth, 
and fifth ribs, a fluctuation of the fluid effused in the 
pericardium. Corvisart has not seen exactly the 
same phenomenon, but he is convinced of its exist- 
ence by the impression conveyed to the hand. Ne- 
vertheless, Corvisart thinks it not unlikely that the 
undulations which he had felt by the hand in one pa- 
tient, were merely produced by the pulsations of the 
heart. The other signs of hydro-pericarditis, ac- 

* According to Corvisart. 



278 DISEASES OF THE PERICARDIUM. 

cording to the same author, are the following :* — ■ 
u Patients affected with hydro-pericarditis usually 
exhibit a countenance of a violet colour, with black 
and livid lips. They experience painful anxiety and 
distressing weight about the region of the heart; dif- 
ficult respiration, which threatens suffocation when 
in the horizontal posture. They are affected with 
syncope, and less frequently with palpitations : the 
pulse is small, weak, frequent, concentrated, and at 
the same time irregular. On applying the hand over 
the region of the heart, tumultuous and obscure pul- 
sations are felt, as if they were conveyed through a 
soft substance, or rather fluid, situated between the 
heart and the walls of the thorax. The precordial 
region gives a flat sound. In some cases, this part of 
the chest is more elevated, round, or bulging than 
elsewhere. When the disease is of long standing, 
oedema of the lower extremities supervenes, and, 
more rarely, slight .pufliness of the anterior left por- 
tion of the chest : the pulsations of the heart are felt 
sometimes at the right, sometimes at the left, in va- 
rious points of a circle, of considerable extent. 

Many of the symptoms mentioned by Corvisart are, 
evidently, common to several other diseases, and, 
consequently, are either equivocal or doubtful : as to 
those which seem to be* peculiar to hydro-pericardi- 
tis, it is highly necessary that they should present 
every desirable certainty. We meet with symptoms, 
also, different from those stated by Corvisart : unfor- 
tunately, auscultation has not, as yet, furnished any 
symptoms calculated to elucidate the diagnosis of pe- 
ricarditis. 

* Ouv. cit. pag'e 50. 



DISEASES OF THE PERICARDIUM. 279 

That which ought to console us for the obscurity 
which envelops the diagnosis, is, that hydro-pericar- 
ditis is almost constantly consecutive; and that, con- 
sequently, the essential point is to be able to recog- 
nise the principal disease. 

The symptoms of pneumo-pericarditis have not 
been very well understood : the undulation and fluc- 
tuation spoken of by Senac and Corvisart may be ob- 
served in the cases of pneumo-pericarditis as w 7 ell as 
hydro-pericarditis. In a subject, whose pericardium 
contained about a pint of serum, and a globe of air 
about as large as an egg, M. Laennec heard a very 
distinct sound of fluctuation determined by the con- 
traction of the heart and strong inspiration. 

Greater resonance of the precordial region would 
be a symptom, undoubtedly, insufficient to announce 
simple pneumo-pericarditis. 

The treatment of hydro-pericarditis should vary, 
according as the disease is either primitive or se- 
condary : in the latter case we should direct our prin- 
cipal means against the essential disease; in the first 
case, which is happily very rare, we should employ 
all the internal remedies, which would be proper in 
dropsy generally. If these means do not succeed, 
some authors advise that the fluid contained in the 
pericardium should be evacuated by a surgical ope- 
ration; but the proper method by which this should 
be done, has not been agreed upon by physicians. 
Senac proposes puncture between the cartilages of 
the ribs, others prefer to make an incision, as has 
been twice done by Desault, between the cartilages 
of the sixth and seventh ribs. M. Laennec does not 
approve of either of these processes, and thinks that 



280 DISEASES OF THE PERICARDIUM. 

it would be much better to trepan the sternum 
above the xiphoid cartilage. This operation is at- 
tended with little danger, [is of easy execution, and 
would permit us to see, and even touch the naked 
pericardium, and verify the diagnosis before opening 
this membranous sac; an advantage which is not to 
be despised when we reflect, that it has happened 
to Desault himself to practise thG operation in cases 
where hydro-pericarditis did not really exist, but 
merely a partial hydro- thorax. 



DISEASES OF THE PERICARDIUM. 281 



SECTION II* 

DISEASES OF THE MUSCULAR SUBSTANCE OF 
THE HEART. 



CHAPTER II. 

OF HYPERTROPHY, OR NUTRIENT IRRITATION OP THE 

HEART. 



PRELIMINARY CONSIDERATIONS. 



The word hypertrophy is derived from the Greek, 
(vrtp, super and rpotpv, nutritio,) and signifies an aug- 
mentation of nutrition. According to MM. H. Clo- 
quet* and Cruvelhier,f when this increase of nutrition 
affects the heart, it constitutes the active aneurism of 
that organ, whence we may perceive that these au- 
thors, as well as other physicians, have confounded, 
until the present time, two things, independent of 



* See, for farther details relative to the treatment of hydro-pericarditis by 
puncture, the article on pericarditis in the Dictionnaire des Sciences Medi- 
cales, (this article is by M. Merat.) M. Richerand has proposed injections 
slightly irritating after the puncture, as is commonly practised in hydrocele; 
but this method would be too dangerous. 

f Anat. Patholog. 

36 



282 DISEASES OF THE PERICARDIUM. 

each other, namely, hypertrophy and dilatation of the 
heart. Since 1811, in a memoir, which we read to 
the Institute, we demonstrated, by facts, that dilata- 
tion does not constantly accompany thickening of the 
walls of the heart; that this thickening may take place 
while the cavity preserves its natural capacity; that 
even hypertrophy may coincide with a contracted 
cavity, as if it had taken place at the expense of the 
last. The expression, active aneurism, then, so far 
as it denotes an increase of nutrition, a hypertrophy 
of the heart, is totally incorrect; since it carries with 
it the idea of dilatation, and since the hypertrophy 
may exist not only without dilatation, but even with 
a diminution of the cavity. The numerous facts we 
have collected obliged us to abandon the classification 
of Corvisart, and to distinguish three distinct varie- 
ties of hypertrophy of the heart. 

In the first variety, the parietes of one or more of 
the cavities of the heart are thickened, without any 
augmentation or' diminution of the size of the cavi- 
ties; this is what we call simple hypertrophy. In the 
second variety, the walls are increased in thickness, 
and the cavity enlarged: this is the active aneurism 
of Corvisart: we shall give to this the name of eccen- 
tric hypertrophy. In the third form, the cavity is 
contracted at the same time that the parietes are in- 
creased in thickness: this is the concentric hypertro- 
phy. 

Finally, we understand, with some modern physi- 
cians, by the term hypertrophy of the heart, a fleshy 
muscular thickening of the walls of one or more of 
the cavities, or even of all the cavities of that or- 
gan, whatever may be its size in other respects. 



DISEASES OF THE PERICARDIUM. 283 

Senac and Morgagni, in the last century, have 
well described the existence of this augmented nutri- 
tion; but they always connected the idea of dilatation 
with that of thickening, in their examination of ana- 
tomical facts, as well as in the theory which they en- 
deavoured to establish. Lancisi has committed the 
same error, as well as another, not less important one. 
In fact, far from thinking, like Morgagni and Senac, 
that the thickening increases the force of the heart's 
action, and constitutes the augmented nutrition, he 
compares it to the engorgement and augmented vo- 
lume, produced by the obstruction and stagnation of 
fluids in other viscera; an opinion which M. Portal 
attempted, some time after, to revive. 

Although Morgagni has never separated, in his 
mind, the idea of hypertrophy, from that of dilatation 
of the heart, we find, notwithstanding, in his immor- 
tal work, an example of simple hypertrophy, with a 
natural state of the cavity, the walls of which were 
thickened. He says, positively, elsewhere, that hy- 
pertrophy consists of augmented muscular substance 
of the heart, {pr&ternaturale carnis musculosse aug- 
mentum,) and that it cannot be attributed to any de- 
fect of the fluids, (vitio fluidorum,) as Lancisi sup- 
posed. 

Corvisart, following in the same track with Morgag- 
ni, rendered a great service to medicine, by recalling 
the attention of French physicians to diseases which 
had been, perhaps, too much neglected. He did not 
consider, it is true, that dilatation, with thickening and 
tenuity, had been already noticed in the works of his 
predecessors, and he distinguishes them by the name of 
active and passive aneurisms. Hypertrophy, with- 



284 DISEASES OF THE PERICARDIUM. 

out augmentation, and even with diminution of the 
cavities, did not attract his attention, although he 
had once seen simple hypertrophy, as we may perceive, 
at the 335th page of the third edition of his work, 
where he speaks of a patient affected with aneurism 
of the aorta, 

" The walls of the left ventricle," says he, " with- 
out being dilated, were much thicker and stronger 
than common; and," adds he, u this increased force 
of the left ventricle, explains how the curvature of 
the aorta, which had received the full force of the 
blood from the ventricle, too strong to yield, had un- 
dergone a dilatation, which the heart had opposed." 

This remark recalls an observation of Morgagni : 
Ventriculus dexter caveam quidem secundum natu- 
ram, sed crassissimas parietes habtbat. — (Epist. xvii. 
art. 21.) 

Bruserius has made similar observations, if we may 
rely upon the following passage of his Institutions of 
Medicine : " Interdum moles tantum cordis ipsa vi- 
detur aucta, quin tamen justo major cavearum ampli- 
tudo dici possit." 

It is evident that these authors, and Corvisart, in 
particular, had only one step farther to make to in- 
clude this form of hypertrophy in the general theory 
of the diseases of the heart. Undoubtedly, every one 
has been surprised on opening bodies, to observe ex- 
traordinary thickening of the left ventricle of the 
heart, without any other change of capacity; but for 
want of observations sufficiently numerous and pre- 
cise, anatomists have been contented to notice the 
fact, without drawing any inference from it. 

At the period when we began to observe this kind 



DISEASES OF THE PERICARDIUM, 285 

of hypertrophy, in persons who had presented some 
of the general symptoms of diseases of the heart, we 
had already pointed out its influence in apoplexy, 
but not its characteristic signs; and we, farthermore, 
could not habituate ourselves to the idea of separating 
this hypertrophy from the dilatation so frequently 
connected with it: the term active aneurism always 
seemed, to us, to be the most proper expression. 

The individuals in whom we observed simple hy- 
pertrophy^ were exempt from any complication of 
softening of the heart's texture, and presented us 
with the same symptoms as those which Corvisart at- 
tributes to active aneurism. From this we ought to 
conclude that the vibration of the pulse, the violent 
and sudden pulsations of the heart, which Senac, 
Morgagni and Corvisart had observed, in cases of ac- 
tive aneurism, could, by no means, be peculiar to any 
one species of dilatation of the heart, and that we 
ought not to attribute them to any thing but an ex- 
cess of energy of the parietes proportionate to the hy- 
pertrophy, whatever may have been, in other re- 
spects, the state of the cavities; the excess of energy 
is sometimes such as to produce active hemorrhages 
of various kinds, and, among others, apoplexy. 

Such was the state of medical science, on this point 
of anatomy, in 1811, when, on the 8th of August, 
we presented to the Institute a memoir on the . sub- 
ject, which was reported by M. Corvisart. The 
simple hypertrophy of the parietes of one or more 
cavities of the heart, is, for the most part, rather a 
morbid than an organic lesion. It is not mortal of 
itself, but becomes so in consequence of the affec- 
tions it produces, and which it determines or com- 



286 DISEASES OF THE PERICARDIUM, 

plicates; but it is quite necessary that it should ex- 
ist frequently, and for a long time, in a state of sim- 
plicity. Sometimes it is accompanied with a dilata- 
tion of the cavities in which it is situated, sometimes 
with a cartilaginous or osseous degeneration of the 
valves or vegetations of these parts, &c. We may 
easily conceive that the diagnosis of hypertrophy is 
much more uncertain in proportion to its complica- 
tion with a greater number of lesions. This remark 
is of great importance, and imposes on all those who 
may hereafter occupy themselves with the diseases 
of the heart, the law of imitating the wise reserve of 
Morgagni; otherwise we might, it is true, present 
brilliant pictures and expositions, which, however, 
would never stand the test of severe analysis, and 
which would be contradicted by the very facts from 
which they had been composed. 

It is indispensable, therefore, to take into account 
all the complications; to proceed from the simple to 
the complex, and to have always present in the mind, 
the wise reflection of Michelotti: " Cavendnm est, 
ubi plura simul vitia deprehenduntur, ne sine certa 
ratione, unum aliquod, potessimum pro morbi causa 
proponantur" 

It is much to be desired that in treating of the se- 
veral diseases of the heart, we might begin with those 
cases in which this lesion only is found; but the inti- 
mate relation which subsists between the different 
parts of the heart, and between that organ and many 
others, the lungs, in particular, explains, sufficiently, 
why such cases are very seldom found. 

We shall begin, nevertheless, with the most sim- 
ple facts, and present several examples, successively. 



DISEASES OF THE PERICARDIUM. 287 

of the three forms of hypertrophy which affect the 
several cavities of the heart, collectively or indivi- 
dually. Afterwards, we shall bring together the re- 
sults of the several cases for the purpose of forming a 
general history of hypertrophy. 



ARTICLE I. 
CASES OF HYPERTROPHY OF THE HEART, 

SECTION I. 

CASES OF HYPERTROPHY OF THE LEFT VENTRICLE, 



L— SIMPLE HYPERTROPHY. 

Case LXXIV. 

Pulsations of the Heart, Strong, Concentrated, and dull; Apo- 
plexy — Simple Hypertrophy of the Left Ventricle; Effusion of 
Blood in the Ventricles of the Brain. 

Francois Pechard, sixty-five years of age, paver, 
having a large and short neck, of a sanguine temper- 
ament, middling stature, and strong constitution, of 
a mild and tranquil character, had been subject, for 
four or five years, to headachs and giddiness, some- 
times followed by momentary loss of sense: these ac- 
cidents were ordinarily relieved by free bleeding 
from the nose. For several days this man suffered 



288 DISEASES OF THE PERICARDIUM, 

more distressing vertigo than usual, and was waiting 
until an epistaxis should happily relieve him, when, 
on the 13th of September, 1822, while he was at 
work with his companions, he fell down, suddenly, 
deprived of sense. He was carried to the hospital 
Cochin, where we examined him at ten o'clock in 
the evening. He was lying on the back, and im- 
moveable; he had vomited a greenish bile, and passed 
his feces in bed: his face was injected, his head in- 
clined to the right, and the mouth was turned to the 
same side; the right pupil was more dilated than the 
left; we observed a total loss of consciousness, sensa- 
tion and voluntary motion; the right extremities were 
affected with automatic spasms, but the left, when 
raised and left to their own weight, fell like inert bo- 
dies; respiration was alternately slow and stertorous; 
pulse full, strong, superficial, and rather frequent; 
the pulsations of the heart, and particularly of the 
left ventricle, were strong, concentrated, and heavy. 
Diagnosis. — Hypertrophy of the left ventricle; 
cerebral hemorrhage. — (The patient was immediately 
bled xvi|, and synapisms applied to the feet.) 14th, 
Nine o'clock in the morning, little amendment, some 
convulsive movements of the left arm, intermittence 
and irregularity of the pulse. (Bled xii§. x grs. tart, 
ant. for a draught, to be taken a table spoonful every 
hour.) During the day the following circumstances 
were observed: Difficulty of deglutition, continua- 
tion of intermittent stertor; the left arm more para- 
lyzed; when pinched made a slight movement to draw 
away, the lids, the globe of the eye, the eyebrow 
and alse of the nose, especially the right, are agitated 
by convulsive motions; the patient moves the lower 



DISEASES OF THE PERICARDIUM. 289 

jaw as if he were ruminating; the chest seems to 
dilate entirely from the contraction of the diaphragm; 
no vomiting; borborygmus, hiccup, involuntary de- 
jections, general perspiration. At ten o'clock in the 
evening, pulse more irregular, and slow; deglutition 
more laborious, paralysis of the limbs complete. 
Morning of the 15th, stertorous snoring continued, 
but less noisy, strabismus, rolling of the eyes, con- 
vulsive motions of the alse nasi, no appearance of 
either sensation or motion. (Same draught, twenty 
leeches to each temple, blisters to the legs.) In the 
evening, face pale and livid, sweating, alternate sus- 
pension of respiration and stertor; pulse small and 
very unequal, dejections involuntary, no vomiting — 
Death at 8 o'clock. 

Inspection of the Body, twelve hours after death. 

Body that of a man robust and well-formed; face 
pale, not swollen; lungs voluminous, very crepitant, 
adhering, and but little swollen in the most dependent 
parts. Heart of a rounded form, and one quarter or 
more larger than the fist of the subject. The aug- 
mentation of volume is to be attributed, exclusively, 
to the hypertrophy of the left ventricle, which seems 
to form the whole heart, and the parietes of which, 
at the middle part, seem to be about fourteen lines 
in thickness: this diminishes towards the superior 
part, and, also, a little towards the base : the fleshy 
columns are much enlarged; the cavity of the ventri- 
cle is evidently of its natural size. The right ven- 
tricle appears to be only a kind of appendix to the 
left. The ventricular septum, hypertrophied in the 
same proportion as the left ventricle, seems to belong 

37 



290 DISEASES OF THE PERICARDIUM. 

to it exclusively. The two auricles are thickened, 
the right is larger than the left. The texture of the 
heart is red, strong, and of a cherry hue. The ori- 
fices and their valves are in the natural state. The 
left coronary artery is considerably larger than the 
right. The aorta, dilated at its origin, puckered 
and bunched on the exterior, contains clots of blood. 
Its internal surface is yellow, rugose, ulcerated, co- 
vered with plicae, some of which are cartilaginous, 
while the rest are ossified and thin, resembling egg- 
shells. The surface of the ulcers is red; the arterial 
texture about them is friable, and, as it w r ere, earthy, 
affecting both the internal and middle coat. The pa- 
rietes of the aorta, thickened throughout their whole 
extent, produce a grating noise on division; they re- 
act, however, with sufficient strength when the fin- 
ger is introduced into the cavity of the artery. The 
vessels of the cellular membrane are very numerous, 
red and somewhat injected. The fibrinous coat, in 
which several of the osseous plicae, above mentioned, 
are apparently situated, is easily separated from the 
others. The arteries, which arise immediately from 
the aorta, those of the base of the cranium and their 
ramifications, the ophthalmic, are equally incrusted 
with cartilaginous, calcarious or chalky laminae. The 
abdominal organs are in the following state: The 
circumvolutions of the small intestines are contracted; 
they, nevertheless, contain bile, as well as the sto- 
mach. The mucous membrane of the latter is gene- 
rally red: its rugae are very large and of a beautiful rose 
colour; the mucous membrane of the small intestine is 
generally pale. The mucous membrane of the large in- 
testine presents a greenish ground, which are traced on 
arborescent figures; of a rose colour, or still deeper 



DISEASES OF THE PERICARDIUM. 291 

tint. The liver is swollen with blood. The gall blad- 
der is filled with black bile. The bladder, distended 
with urine, rises considerably above the pubis. The si- 
nuses of the dura mater are swollen with blood; the me- 
ninges are considerably infiltrated, especially toward 
the cerebral depressions. The lateral ventricles are 
dilated by a great quantity of fluid blood; however, 
the effusion is more considerable in the right ventri- 
cle than in the left; their septum is torn. The cere- 
bral substance is firm and dotted with blood. 

In the case of hypertrophy, which we had disco- 
vered by auscultation, it is worthy of notice that there 
was not that lividity of face, that capillary distention, 
that infiltration, those paroxysms of suffocation, which 
authors regard as inseparable from what they call 
aneurism, or, indefinitely, hypertrophy of the heart. 
In fact, these symptoms do not appertain to hyper- 
trophy, and indicate, on the contrary, an obstacle to 
the circulation. Now, in the present case, there was 
not only no obstacle to the course of the blood, but 
the movement and impulse communicated to the 
blood were so active and impetuous, that hemorrhage 
took place in consequence of it, during one of which 
the patient died. 

We shall see the same accident repeated in the 
following cases. 

Case LXXV. 

Hypertrophy of the Left Ventricle, without Dilatation of its Ca- 
vity; Cerebral Hemorrhage. 

A joiner, named Hassenpatz, forty-five years of 
age, of a strong constitution, admitted to the hospital 
Cochin the 15th of February, 1810, had been for three 



292 DISEASES OF THE PERICARDIUM. 

years affected with great difficulty of respiration, and 
rather frequent palpitations. On entering, his face 
was red, and, as it were, injected; the pulsations of 
the heart were violent, but regular and circumscribed; 
the pulse was also regular and vibrating. — Percus- 
sion gave only a flat sound in the region of the heart. 

Two days after his admission, this man w r as at- 
tacked suddenly with hemiplegia of the whole left 
side, with paralysis of the upper lid of the same side, 
and difficulty of speaking. 

Bleeding, another means appropriate in such cases, 
subdued these accidents. Speech became more free, 
the motions of the upper lid began to be re-esta- 
blished; but, on the 23d of February, a new apoplectic 
attack suddenly occurred, and carried off the patient. 

Inspection of the Body. — We found the sinuses 
distended with blood, and a large quantity of this 
fluid effused into the lateral right ventricle, and into 
the substance of the hemisphere of the same side. 

The parietes of the left ventricle of the heart were 
much thicker than in the natural state, without its 
cavity having been either augmented or diminished 
in extent. 

The two auricles and the right ventricle, as well 
as the several orifices and their valves presented no- 
thing extraordinary. 

The other viscera were healthy. 

Case LXXVI. 

Simple Hypertrophy of the Left Ventricle; Apoplexy from 
Congestion* 

Madelline Piquet, sixty-five years of age, of a ro- 
bust constitution, but weakened by distress, entered 



DISEASES OF THE PERICARDIUM. 293 

the hospital Cochin on the 11th of March, 1811. 
She only complained, at that time, of diarrhoea ac- 
companied with colic. This woman had a large 
head, rather short neck, a strong voice and consi- 
derable embonpoint. She was subject to frequent 
headaches, vertigo, and stupor. The pulse was re- 
markably strong and vibrating; the pulsations of the 
heart were very strong, abrupt, and, as it were, de- 
tached, without being felt through a great extent. 
Nevertheless, the patient did not complain of having 
suffered palpitations before she entered the hospital. 
We prescribed both general and local bleeding. 

After ten days' treatment, this patient began to re- 
cover, when, while walking in the garden, she was 
suddenly seized with vertigo, violent headach, de- 
sire to vomit and great difficulty of respiration. 

Having been carried immediately to bed, she soon 
lost the use of speech, sensation, and voluntary mo- 
tion, the face became redder and more injected; the 
lids were depressed as if paralyzed, the mouth was 
drawn on one side; the pulse, always strong and vi- 
brating, became more frequent. In vain was full 
bleeding practised; in vain did we resort to an eme- 
tic draught, and sinapisms; the patient died in twelve 
hours after the attack of this frightful apoplexy. 

Inspection of the Body. — The lungs were healthy, 
the heart appeared sufficiently large, the parietes of 
the left ventricle were thickened, a full inch, in the 
whole of their extent, except towards the apex of the 
heart; its cavity was in the natural state, the colum- 
nar carneae were very large. — The right side of the 
heart offered nothing peculiar. It was the same with 
the left auricle, the valves, and the large vessels. 



294 DISEASES OF THE PERICARDIUM. 

All the cerebral vessels were distended with blood. 
We observed coagula of this fluid in the groove which 
separates the tuberculum annulare from the medulla 
spinalis: these coagula were prolonged from one side 
to the other, within the ventricle of the cerebellum, 
which they filled, even extending into its substance, 
where they had formed a nidus. — The other ven- 
tricles were full of bloody serum. 

The abdominal viscera offered nothing extraordi- 
nary. 



II— ECCENTRIC HYPERTROPHY WITH DI- 
LATATION. 

Case LXXVII. 

Hypertrophy of the Left Ventricle icith Enlargement of its 

Cavity. 

Denis Angelot, tailor, twenty-two years of age, of 
a sanguine temperament, w T as admitted into the hos- 
pital Cochin the 12th of January, 1813, presenting 
the symptoms of acute rheumatism. He complained, 
at the same time, of pain in the left side, towards the 
base of the chest, which bulged out, and was sono- 
rous in its whole extent. The pulse was strong, full 
and vibrating, the pulsations of the heart were also 
very distinct; the face was a little pale; the skin co- 
vered with copious sweat; the tongue moist and 
white; the abdomen tense, and sensible on pressure. 

The second day of entrance, the pains of the joints 
wfere more acute, the least motion rendering them 
insupportable, respiration painful, tongue red at the 



DISEASES OF THE PERICARDIUM. 295 

edges, thirst very urgent; chill, which lasted from 
two to three o'clock, was followed by violent heat 
and copious sweat; the pulsations of the heart were 
stronger, and vibrations of the pulse more distinct. 

Same state, on the third and fourth day. On the 
fifth, the symptoms were a little diminished; but on 
the following days the rheumatic pains attained to the 
highest degree of intensity. They subsided on the 
eighth, and the swelling of the joints diminished; ne- 
vertheless, the pulsations of the heart increased in 
force. — Ninth day, pungent pain towards the twelfth 
left rib, removed by bleeding to the extent of twelve 
ounces. The pulsations of the heart, at the same time, 
lost their intensity, the pulse became softer, but the 
pain in the side was renewed, the next day, with 
palpitation and vibration of the pulse. Twelfth day, 
the symptoms of rheumatism had disappeared; but the 
heart continued to beat with the same violence, and 
the pulse vibrated as usual. Constipation was removed 
by laxatives. 

Fifteenth and sixteenth days, pulsations of the heart 
and vibration of the pulse less marked* 

For some days following, the patient thought his 
health entirely re-established, and was disposed to go 
out. 

1st February, experienced anew a somewhat acute 
pain in the same side of the chest; this ceased in the 
evening; was renewed, with more violence, next dayj 
again disappeared; returned the following day, and 
continued. 

5th February, towards evening, the patient having 
walked a good while in the garden, suffered a violent 
chill, followed by nausea and vomiting; cough; very 



296 DISEASES OF THE PERICARDIUM. 

acute pain in the side; painful respiration, and even 
stertorous tumultuous palpitations. He was bled in 
the arm, about midnight, with so much relief, that, 
the next day, he could get up and walk; but the same 
symptoms were renewed in the evening. 

8th February, expectoration of blood has super- 
vened; the limbs have begun to infiltrate; the extre- 
mities are cold; the pulse is small and irregular; the 
patient speaks only with the greatest difficulty; his 
words are interrupted by sighs and sobs. Ninth of 
February, he is getting into a comatose state; his re- 
spiration is noisy and loud, and the face, which has 
been constantly pale, now presents a cadaverous hue. 
Death occurred, the day following, at eight o'clock 
in the evening. 

Inspection of the Body. — The lungs were much en- 
gorged with blood: the left lung was a little reflected 
towards the superior part of the chest, where it was 
united by several adhesions to the costal pleura. The 
pericardium contained a yellow serum. The heart 
was very large. — The parietes of the left ventricle 
were more than an inch thick, towards the base; the 
hypertrophy diminished, gradually, towards the apex, 
where it was also very distinct. The columnar ear- 
ner were more developed than in the natural state; 
the cavity of the ventricle was more than double the 
usual size. 

The left auricle, and the valves, presented nothing 
extraordinary. — The walls of the right ventricle 
were thin, but its cavity was in the usual state, as 
well as the auricle of that side. — The caliber of the 
aorta was remarkably small, not only compared with 
the capacity of the left ventricle, but in reality. 



DISEASES OF THE HEART. 297 

We know that M. Portal, from an opinion which 
he had formed on the nature of thickening of the pa- 
rietes of the heart, has been led to regard all aneurisms 
of the heart as passive. Here we shall present some 
researches, which prove how far M. PortaPs mode of 
observation is conformable with truth. After having 
examined the heart of a patient, previously to this 
celebrated physician, we sent it to M. Chevalier, stu- 
dent of M. Vauquelin, requesting that he would make 
some chemical experiments on the left ventricle, 
compared with another which was, in every respect r 
healthy. Both these ventricles, examined with a 
lens and miscroscope, presented no other difference, 
excepting that the muscular fibres of the hypertro- 
phied left ventricle, were more of a vermilion colour 
than those of the other. Two portions of the same 
weight having been put into distilled water, the por- 
tion which appertained to the thickened ventricle, 
coloured the water very distinctly, and, when taken 
out, was considerably redder than the other. The 
two ventricles were, afterwards, submitted to the ac- 
tion of boiling alcohol, to ascertain which of the two 
contained the greatest quantity of fatty substance. 

Now, the result of this experiment was, that the 
hypertrophied ventricle contained a less quantity of 
this matter than what was found in the healthy ven- 
tricle.* 

* This result is in direct opposition with the opinion of Lancisi and of M. 
Portal. 



38 



298 DISEASES OF THE HEART. 

Case LXXVIII. 

Pulsations of the Heart, very similar to the Blows of a Hammer; 
Paralysis of the Left Side, with Stiffness of the Right Arm; 
Crying and Agitation. — Hypertrophy, with Slight Dilatation 
of the Left Ventricle; Arachnitis; Softening of the Right He- 
misphere of the Brain. 

Jeanne Bossuet, 79 years of age, domestic, tall, 
thin, pale and nervous, was brought to the hospital 
Cochin the 12th of June, 1822. The persons who 
conveyed her could give us no other information, ex- 
cepting that she had suddenly lost her senses, fifteen 
days before; that the intellectual faculties partially 
returned, for a few minutes; but that, afterwards, the 
left side had remained paralyzed. The symptoms 
presented by the patient, on arrival, were the follow- 
ing: Head inclined to the right, mouth turned the 
same way, tongue drawn a little to the left, when pro- 
truded, which is very difficult; pupils equal; mobile; 
face expressing a kind of stupid astonishment; para- 
lysis of the left limbs, weeping, agitation, loquacity, 
subdelirium. All the arteries, but especially the ca- 
rotids, beat with force, and the pulse is somewhat 
frequent. The clothes of the patient are raised up 
by the forcible pulsations of the heart, which are 
strong, remarkably distinct, and repel the hand vi- 
gorously, when applied over the precordial region. 
Explored, with the cylinder, they resemble, very 
much, the blows of a hammer, and produce a distinct 
and quite clear sound. 

Diagnosis. — Hypertrophy of the heart, and in- 
flammation of the brain. Such severe diseases, in 
connexion with the advanced age of the subject, did 



DISEASES OF THE HEART. 299 

not permit us to hope for a cure, and we were con- 
tent with prescribing an infusion of arnica. 

At the time when the face lost its expression, the 
superior right extremity became stiff, and resisted 
extension; the patient completely sunk in the coma- 
tose state, uttered groans and cries, and died in the 
course of the fifth day after entrance. 

Inspection of the Body thirty hours after Death. 

The two lungs are perfectly crepitant; the right is 
adherent. The pericardium is injected; the heart is 
much larger than the fist of the subject. The right 
ventricle, enveloped in a larger quantity of fat, is, in 
other respects, healthy. It does not contain blood, 
nor does the corresponding auricle, the fleshy co- 
lumns of which are very strong. The left ventricle 
is hypertrophied. Its walls, at the base, are about 
eleven lines in thickness, the ventricular septum is 
about seven lines thick. The columnse of the left 
ventricle are very numerous; its capacity is somewhat 
greater than that of the right. The walls of the left 
auricle are thickened. The texture of the ventricles 
is red and dense. The coronaries are formed, in bold 
relief, upon the surface of the heart; their parietes 
are hard and ossified throughout their whole course. 
Yellow points are observed in all the valves of the 
heart; the aortic valves are even strewed with seve- 
ral osseous calcarious plates. The origin of the 
aorta is dilated: in the whole length of this artery, 
the internal surface is unequal, covered with yel- 
low earthy laminae, and calcarious scales, analogous 
to egg-shells, but thicker; several of w T hich have 
the internal membrane raised. The arteries which 



300 DISEASES OF THE HEART. 

arise immediately from the aorta, those of the extre- 
mities, and especially the pelvic; the arteries of the 
base of the cranium, and the ophthalmic, partake of 
the degeneration of the aorta; their cellular mem- 
brane is much injected:* The trunk of the superior 
mesenteric artery is entirely ossified, and forms a 
hard inflexible tube; but the greater as well as lesser 
branches, distributed to the digestive organs, are ex- 
empt from this change. The arterial system, through- 
out, is distended with liquid blood, whilst the venous 
system, in a state of collapse, contains hardly any. 
The circumvolutions of the small intestine, are small 
and ^contracted. The rectum is distended by indu- 
rated feces. The mucous membrane of the stomach, 
is of a deep red in the region of the spleen. There 
is a great quantity of serum in the base of the cra- 
nium, and in the ventricles. The arachnoid, which 
covers the superior circumvolutions of the brain, is 
opaque and of a milky colour. The posterior lobe 
of the right hemisphere, offers a deep yellow tint: it 
is softened and somewhat deliquescent. In its centre 
there is a whitish, creamy matter, much resembling 
pus; its substance offers, in other respects, consider- 
able redness and injection, and is disseminated with 
minute clots of blood, as well as yellow masses, of a 
larger size, easily broken down, which are internally 
filled with blood. The nidus is covered with very fine 
membrane, overrun with red vessels, and can be very 
distinctly observed. The arachnoid, which enve- 
lops the softened circumvolutions, adheres so closely 
to them that they appear to be confounded together. 

* It is rather remarkable that the primitive carotids had, in someway, es- 
caped alteration. 



DISEASES OF THE HEART. 301 

The remaining portion of the brain is without any 
remarkable alteration- The plexus, and choroid 
membrane contain hydatidiform globules. 

Case LXXIX. 

Aneurismal Hypertrophy of the Left Ventricle, Hydrothorax; 
Tapeworm in the Ilium, Spc. 

Peter Brisson, mason, of rather diminutive stature, 
but strong constitution, remarked that he had been 
sick only fifteen days when he entered the hospital 
Cochin, the 13th of June, 1822. The alarming state 
in which we found him led us, however, to suppose 
that his disease began at a more remote period. He 
was in the following condition : pain in the middle of 
the thorax and precordial region, where the patient 
experienced an insupportable sensation of oppres- 
sion. Cough, orthopncea, strong, vibrating and re- 
gular pulse; pulsations of the heart scarcely sensible 
to the hand: (the extreme pain and agitation did not 
permit us to practise auscultation:) headach, vertigo, 
frequent loss of sight; distressing insomnia; face pale 
and swollen; lips large, and somewhat livid. 
Diagnosis. — Aneurism of the heart. 
Prescription. — (Ptisan aperit. jul. digital.) 
16th of June, four days after entrance, patient in- 
cessantly threatened with suspension of respiration; 
could no longer lie in the horizontal posture; fright 
and anxiety depicted in the countenance. 17th, the 
patient remains sitting, supported on the edge of the 
bed; the head depressed, and the body inclining for- 
ward : he groans, and is panting : implores our assist- 
ance, and begs that we would not let him die. We 



302 DISEASES OF THE HEART. 

opened a vein in the arm, but the blood would only 
flow by drops; which obliged us to substitute for ve- 
nesection the application of thirty leeches to the re- 
gion of the heart. 18th, skin cold, oedema of the 
right foot. (Blister to the right foot.) About two 
hours' sleep the following night. 19th, stormy and 
rainy day; rapid increase of all the symptoms, suffo- 
cation, frightful distress; the patient, naked, sitting 
on his chair; the body strongly bent forward; the 
head, supported on the edge of the bed, can no longer 
maintain any other position, and sudden death is ex- 
pected. 20th, situation more and more deplorable; 
convulsive contraction of the diaphragm; imminent 
suffocation; face more swollen; eyes distorted; skin 
cold, desire of death; which, finally, occurred at ten 
o'clock in the morning. 

Inspection of the Body, twenty-one Hours after Death. 

1st. External Appearance. — Body well formed : 
the limbs are infiltrated, and their veins distended 
with blood. 

2d. Respiratory and Circulatory Organs. — Flat 
sound of both sides of the chest; effusion of a large 
quantity of slightly red coloured serum in the two 
cavities of the pleura. The two lungs, of rather 
small size, pressed by this liquid and the enormous 
mass of the heart, yet retained a crepitating texture, 
although condensed by compression. The pericar- 
dium contained a small quantity of reddish serum. 
The heart, swelled with blood, and of enormous size, 
(four times as large as the fist of the subject,) occu- 
pies as much space as both lungs together. It is si- 
tuated transversely, in such a manner that its base 



DISEASES OF THE HEART. 303 

slightly compresses the right lung, while the two 
ventricles press with their whole weight on the left 
lung. The heart, disembarrassed of the fibrinous 
black clots which distend it, still retains its extraor- 
dinary size. 

The left ventricle is about three times the natural 
size, and its parietes about six lines thick. Its tex- 
ture is red, and tolerably firm. The left auricle is 
excessively small, compared with the ventricle, and 
is capable of containing a hen's egg. The right ven- 
tricle is much larger than the left, and, although a 
little dilated, retains its usual thickness. The thick- 
ness of this ventricle is pretty uniform throughout its 
whole extent, as is also the case with the left, but 
diminishes a little towards the apex. The right au- 
ricle is thick and fleshy, and is about one-third larger 
than the left. The orifices of the heart are healthy. 
The aorta and pulmonary artery are distended with 
clots of blood: the curvature of the former is appa- 
rently dilated, whilst its orifice is, perhaps, a little 
contracted. 

3d. Abdominal Organs. — The mucous membrane 
of the stomach, the small and large intestine, present 
a deep red colour, analogous to that of the kermes 
mineral, produced by the mechanical distention of 
the red vessels. A living taenia lay along the whole 
length of the intestinum ileum. The liver and spleen 
are distended with blood. The bladder is contract- 
ed, and is, internally, of a rose-colour. 

4th. Encephalic Organs. — The scalp is also swol- 
len with blood; there is a very considerable quantity 
of serum in the arachnoid. That portion of the mem- 
brane which covers the convexity of the brain ad- 



304 DISEASES OF THE HEART. 

heres to the parietal portion, and presents, here and 
there, various granulations; on the sides of the he- 
mispheres, the arachnoid is opaque, milky, and in- 
jected; the cerebral substance is very soft. 

In the case we have just related, the hypertrophia, 
instead of being found in the substance of the pari- 
etes, was at the surface. Although the substance of 
the parietes was evidently in a healthy state, the hy- 
pertrophy was, notwithstanding, unusually large, the 
left ventricle being three times as large as in the na- 
tural state. * 

We might mention a great number of cases of hy- 
pertrophy with dilatation of the left ventricle. This 
form is the most common; it is, also, that which au- 
thors have exclusively studied under the name of ac- 
tive aneurism. But we shall confine our attention, 
here, to the cases we are about to read. We would 
refer those who wish for other facts of the same kind, 
to the following cases; namely, the twenty-seventh, 
thirty-third, thirty-fifth, thirty-seventh, thirty- 
eighth, forty-second, forty-ninth, fifty-third, fifty- 
ninth, sixty-second, sixty-third, and sixty-ninth; all 
of which contain remarks respecting hypertrophia, 
with dilatation of the left ventricle. 

Let us pass to a form of hypertrophia, less known, 
that with contraction of the cavity. 

The illustrious Senac has devoted one of the arti- 
cles of his work to the diminished volume, contrac- 
tion of the cavities, smallness and desiccation of that 
organ. The cases which we shall present have no 

* This hypertrophy proceeded in a very rapid and acute manner, since the 
patient observed to us, that he was affected with the symptoms which an- 
nounce it only fifteen days before he entered. 



DISEASES OF THE HEART. 305 

analogy with the facts cited by Senac; all of which 
he "has- borrowed, as usual, from other writers. la 
the cases recorded by Malpighi, Littre, Fabricius, 
and Hildanus, the heart was very small r wrinkled, 
and shrunken. In those we have collected, the vo- 
lume of the heart is not diminished: the walls, in- 
deed, are thicker and more fleshy, but the thick- 
ening is formed at the expense of the cavity, the 
capacity of which has proportionably diminished, 
We have sought in vain among authors for cases 
which resemble our own. Here, however, is what 
the author of an extract from the work of Corvisart 
has inserted in the Dictionnaire des Sciences Medi- 
cates: — " In opposition to the aneurisms of the heart, 
we ought to mention the state of that viscus in which 
its cavities are faund remarkably contracted. These 
cases are most commonly overlooked, and have never 
been sufficiently investigated to enable us to speak of 
them so fully as they deserve. Perhaps a more ex- 
tended inquiry than has yet been made may reveal 
more interesting views. I shall be satisfied by ob- 
serving that I have frequently seen the ventricles, es- 
pecially the left, much less capacious than the strength 
and stature of the subject required. There was, most 
frequently, a rigidity of the fibres, which led me to 
perceive that that state was constant and morbid. In 
the same way that we perceive a heart to be aneuris- 
mal by comparison with the body of the individual 
in whom it exists, in like manner do we discover its 
diminished volume; because the whole of the heart 
may be in this condition, as well as either of its cavi- 
ties. It is true that the aneurism attracts more at- 
tention than the diminished volume; a fact which 

39 



306 DISEASES OF THE HEART. 

proves that it has been more noticed, and that the 
phenomena connected with it are better known. 
Farthermore, there must be peculiar symptoms cor- 
responding with the latter affection. They have not, 
as yet, been pointed out; and I must acknowledge, 
that having but very few facts on this point of science, 
I cannot establish any which are satisfactory." 

The author of this article does not mention the 
hypertrophy of the parietes, and the cases of which 
he speaks have nothing in common with ours, ex- 
cepting the diminished capacity of one or more of 
the cavities of the heart. We have, also, frequently 
observed a great diminution of the cavity of the ven- 
tricles, from causes unconnected with hypertrophy. 
But this is an entirely different disease; not a form 
of atrophy, but, in fact, a true atrophy of the heart. 
At the time we communicated to Corvisart two re- 
markable examples of this concentric hypertrophy, 
we desired our students to make new researches on 
the subject in the other hospitals of Paris, and to fix 
the attention of our brethren on this important point 
of medical science. We have had the satisfaction to 
learn, that our observations have been confirmed by 
other similar facts collected in the different establish- 
ments devoted to clinical observation. It is of little 
consequence that they have been presented as en- 
tirely new, as discoveries, provided they be useful 
for the advancement of science. But let us return 
to our cases, 



DISEASES OF THE HEART. 307 



III— CONCENTRIC HYPERTROPHY, WITH 
CONTRACTION OF THE CAVITY. 

Case LXXX. 

Violent, dull, and circumscribed Pulsations of the Left 
Ventricle; Palpitations; Paralysis of the Right Arm, 
succeeded by Erysipelas of the Face; Death; Hypertro- 
phia of the Left Ventricle, with Contraction of its Ca- 
vity; Softening of the Brain, Cerebellum, fyc. 

Prudence Sally, forty years of age, domestic, of a 
dry and nervous temperament, born at St. Domingo, 
had suffered palpitations at intervals for eight years, 
when she entered the hospital Cochin the eighth of 
April, 1822. Her menstruation, which had been ha- 
bitually defective, but regular, had ceased only within 
a month. During the three preceding years, she had 
been frequently bled with advantage. In January 
last, (1822,) the right arm had been completely pa- 
ralyzed. At the time of entrance, the paralysis was 
not entirely removed. She could move the limb, al- 
though very feebly. The patient complained of ra- 
ther violent continued headach, occupying particu- 
larly the sides and back part of the head. When 
questioned, she replied with extreme slowness : her 
features disclosed a kind of idiotic stupor; she occa- 
sionally suffered from palpitation and suffocation; the 
pulse was regular, but little developed, yet hard and 
strong; the pulsations of the left ventricle, explored 
with the cylinder, were strong, concentrated, dull, 
and profound. 

Diagnosis. — Hypertrophy of the left ventricle; 
cerebral affection. 



308 DISEASES OF THE HEART. 

We prescribed fifteen leeches to the anus, and an 
infusion of tilia and orange flowers. Nothing remark- 
able in the state of the patient occurred, until the 1st 
of May. At this period, the conjunctiva of the right 
eye was much inflamed; the headach was intolerable, 
and there was constipation. (Emplast. lyttoe ad nu- 
cham, hydromel. sodze sulphas., pedil. sinap.) 

In the mean time, the blister determined a very 
painful swelling of the lymphatic ganglions of the 
right side of the neck, in which were formed several 
ileposites of suppuration. We made a small incision, 
which was followed by relief. 

On the 15th of May, after having been out to walk 
the whole day, the patient had a nervous attack, re- 
specting the symptoms of which we could learn no- 
thing satisfactorily. She stated that she had had a 
great many similar ones. The night following she 
was restless. (Pot. sedativ.; pediluv.) 

16th. Nervous accession has entirely disappeared, 
but the right side of the face is the seat of an (Ede- 
matous erysipelas and fever : some symptoms of deli- 
rium in the day. 

17th. The erysipelas extends to the whole face. 
^Thirty leeches to the neck and face; emetic, whey, 
lemonade, diet.) 

18th. Very high fever, constant tendency to fall 
out of bed; no reply to questions. Called to the pa- 
tient at two o'clock in the afternoon; found her in- 
sensible; lips discoloured, inflammatory swelling of 
the face almost entirely subsided; face pale, lids 
closed, sensation extinct; pulse frequent, and small; 
respiration unfrequent, slow, and accompanied with 
rattle. Meanwhile, the movements of respiration 



DISEASES OF THE HEART. 309 

grow weaker and weaker, the pulse loses its frequen- 
cy, becomes slow, and disappears : the pulsations of 
the heart continue; several half convulsive inspira- 
tions still occur : in a long interval between them we 
thought the patient dead. The hand, applied over 
the region of the heart, feels it still pulsating. Two 
other deep inspirations are observed; the mouth is 
covered with a frothy substance; a kind of tremor is 
observed in the muscles of the fore arm; their ten- 
dons start — respiration ceases — the patient is dead. 

Inspection of the Body forty -eight Hours after Death. 

No rigidity; body without infiltration, well formed. 

1st. Respiratory and Circulatory Organs. — The 
two lungs are healthy. The heart, swollen with 
blood, and twice as large as the fist of the subject, 
fills the whole anterior left side of the chest, as high 
as the clavicle. The orifices present nothing worthy 
of observation, excepting the valves. The left ven- 
tricle is very large, and its parietes are more than 
an inch thick at their middle part : the t hie/mess di- 
minishes towards the base and the apex. Some of 
the fleshy columns are also hypertrophied. The ca- 
vity of the ventricle is very perceptibly contracted. 
The two auricles and the right ventricle, the apex of 
which does not descend so far downward as that of 
the left, are nearly in a healthy state: the interven- 
tricular septum is about six lines thick : the muscular 
texture of the heart is red, firm and ruddy. The 
aorta, the caliber of which is rather small, contains 
long fibrinous strings : its internal surface is strewn 
with yellow, earthy, calcarious, or fibrocartilaginous 



310 DISEASES OF THE HEART. 

scales. The same change is observed in the arteries 
of the pelvis and lower extremities, and especially 
those of the brain. The coronary arteries, the ca- 
rotids, and the arteries of the upper extremities, are 
healthy; excepting that the former are larger than in 
the natural state. 

2d. The Abdominal Organs — present various 
changes which it would be unnecessary to relate in 
this place. 

3. Encephalic Organs. — Inflammatory softening 
of the right corpus striatum, and of the middle infe- 
rior portion of the left hemisphere. Softening of the 
central part of the right hemisphere of the cerebel- 
lum. (I have merely alluded to these changes, as it 
would take up too much time, and be superfluous to 
describe them here.) 

Case LXXXI. 

■ • 
Hypertrophy of the Left Ventricle, with Contraction of 

its Cavity. 

Felicite Lange, fifty-eight years of age, washer- 
woman, of a strong constitution, had not been regular 
for thirteen years, when she was received into the 
hospital Cochin, the 2d of December, 1812. She 
complained, for two years, of frequent palpitations; 
her respiration was painful, interrupted, and pant- 
ing: symptoms which had been most decidedly de- 
veloped within eight days; so that the patient was 
obliged to be at perfect rest. The complexion was 
of a livid red, the face swollen, the lips black; ina- 
bility of lying on the left side : percussion gave a flat 
sound in almost every part of the chest; a circum- 



DISEASES OF THE HEART. 311 

stance which might, in part, depend upon the thick- 
ened state of the infiltrated integuments. The infil- 
tration was almost general, although most marked in 
the inferior extremities : the sleep was frequently 
disturbed by sudden starting. The symptoms con- 
tinued nearly the same until death, which took place 
on the 14th of December, twelve days after entrance. 

Inspection of the Body. — The two lungs were in a 
healthy state, excepting that they were united by 
some slight adhesions to the costal pleurae; the cavi- 
ties of the chest and pericardium contained only a 
very small quantity of serum. 

The heart was large, and very much distended 
with blood; its valves were not in the least diseased. 
Considerable hypertrophy was observed in the left 
ventricle, the walls of which, towards the base, were 
nearly an inch and a half thick, and its capacity di- 
minished more than one-half: the left auricle was in 
the natural state. 

The ventricle and auricle of the right side were 
dilated, and their walls appeared somewhat dimi- 
nished in thickness. 

The arch of the aorta was not dilated; but its in- 
ternal membrane was ossified in nearly the whole of 
its extent. This disease has presented us the signs 
of obstruction to the circulation, and nevertheless 
the orifices and valves were not the seat of any le- 
sion; but remark, that the contraction of the cavity 
of the left ventricle ought to produce the same phe- 
nomena that the contraction of the orifices do; and 
we should, therefore, not be astonished that the lips 
of this woman were swollen and black, and the limbs 
infiltrated, &c> 



312 DISEASES OF THE HEART. 



Case LXXXIL 

Hypertrophy of the Left Ventricle^ with Contraction of 
its Cavity. 

Jean Courtin, parchment maker, sixty-seven years 
of age, of a sanguine temperament, for three years 
subject to fits, probably epileptic, had enjoyed until 
thirty years of age, tolerably good health. His mo- 
ther died at the age of sixty-nine, and was affected 
from the age of forty years, with almost continual 
cough, accompanied with dyspnoea, or to speak in 
the language of the patient, with short breath. His 
father died of a catarrhal affection at the age of for- 
ty-five. 

In the course of the month of September, 1814, 
Courtin began to suffer considerable oppression about 
the region of the heart: he continued, notwithstand- 
ing, to pursue his usual avocations until the end of 
November following; but the dyspnoea continually 
increasing, the patient was obliged to suspend work, 
and was admitted to the hospital Cochin on the 1st of 
December. He left it on the 20th, relieved by the 
local bleeding, and anodynes were administered : he 
again resumed his work, but the symptoms already 
mentioned were, in a short time, removed. The 9th 
of January, 1815, he was taken with trembling, fol- 
lowed by fever and cough, and was obliged to keep 
his bed. The 17th of the same month, he entered 
the hospital; his respiration was short, with constant 
oppression in the region of the heart and sense of 
impending suffocation; the percussion of the chest 
was sonorous, but painful toward the left and poste- 



DISEASES OF THE HEART. 313 

rior part; the pulse was regular, small and weak. 
The patient could no longer support the horizontal 
position, and the least motion, in bed excited a dry 
eough. Nevertheless he slept quite well, and with- 
out any starting. There was no oedema; the face 
pale and meagre, like the rest of the body, did not 
announce any disease of the heart. The patient re- 
mained nearly in the same state until the 20th of Fe- 
bruary. Febrile symptoms at that time appeared r 
the habitual cough augmented in violence, and the 
fever having assumed an adynamic form, the patieigt 
died on the 29th of the same month. 

Inspection of the Body. — Close adhesion between 
the contiguous surfaces of the pleura. Texture? of 
the lungs crepitant, very permeable, except at the 
top of the right, where we observed several points 
of induration, in the centre of which there were very 
small tubercular grains. 

The heart was of nearly the natural size, only it 
appeared a little larger than comported with the ge- 
neral structure of the body; the pericardium con- 
tained from three to four ounces of serum; the left 
ventricle was more than double the natural thick- 
ness, and of a round form; the hypertrophy was near- 
ly equal throughout the whole extent of the organ : 
the texture of the pariet.es. was rather firm, but of a 
pale yellow colour: the ventricular cavity was so con- 
tracted, that w T e could with difficulty introduce a 
common-sized filbert. The valves and the other 
parts of the heart exhibited nothing peculiar* 



4Cr 



314 DISEASES OF THE HEART. 

SECTION II. 

CASES OF HYPERTROPHY OF THE RIGHT VENTRICLE. 

/. SIMPLE HYPERTROPHY. 
Case LXXXIII. 

Simple Hypertrophy of the Right Ventricle; Simple Dilatation of 

the Left Auricle 

Marie Therese Hubert, sixty-four years of age, 
subject to catarrhal affections, had suffered from the 
age of forty-five years, the period of the cessation of 
her menses, the most depressing sensations, and be- 
gan to suffer from palpitations, paroxysms of suffoca- 
tion, and anxious distress about the precordial region. 
This woman was relieved by the application of leeches 
to the anus. She suffered, for a long time afterwards, 
a variety of troublesome disorders only, and the pri- 
mitive disease, having remained stationary, and as it 
were stifled, was not renewed, and did not exhibit 
any alarming severity until she was sixty years of age. 
At that time she slept little or none; and, when she 
did, it was interrupted by starting : respiration be- 
came more and more difficult, and as it were suspi- 
cious, and a sense of suffocation occurred upon the 
least exercise. On entering the hospital Cochin, on 
the 14th of October, 1815, the patient was very weak; 
the pulse could hardly be felt, while the pulsations of 
the heart were very strong, precipitous, and could be 
felt and even seen in a great extent of the chest: the 



DISEASES OP THE HEART, 315 

skin was pale and livid, the face depressed, and the 
patient complained of being universally cold. The 
hands, feet, legs and thighs were infiltrated, and as 
cold as marble. The horizontal position was impos- 
sible : percussion of the chest gave a flat sound. The 
patient, overwhelmed with anxiety, expired four days 
after her entrance, without having suffered any new 
symptom which would lead us to suppose she was so 
near her end. 

Inspection of the Body. — The respiratory organs 
were in the natural state. 

The pericardium was very large, and distended 
by a pint of limpid serous fluid. 

The heart, of good size, offered nothing remarka- 
ble excepting a dilatation of the left auricle, without 
any change of the thickness of its walls; and a thick- 
ening of the parietes of the right ventricle, so consi- 
derable as to render them equal to those of the left, 
and without its cavity being either augmented or di- 
minished in extent. The hypertrophy was nearly 
equal and uniform in the whole extent of the parietes 
of the ventricle. The left ventricle was thinner and 
softer than in the natural state. The valves of the 
heart and large vessels were healthy. 

We once gave Corvisart a case analogous to the 
preceding, but have not kept a copy of it. We re- 
collect, however, that the hypertrophy of the right 
ventricle terminated by a congestion of blood in the 
lungs, resembling pulmonary apoplexy: the right 
ventricle was in a state of hypertrophy, and had pro- 
duced on the pulmonary artery and the lung a similar 
effect to that which hypertrophy of the left ventricle 
produces on the brain, during the formation of cer- 
tain hemorrhages of that organ. 



316 DISEASES OF THE HEART. 

It is sufficiently worthy of remark, that, in most 
cases of hypertrophy, whether simple or otherwise, 
the left ventricle is soft and flabby, as if there had 
been a transposition of the ventricles, and one of 
them had usurped the place of the other. 

After having searched Morgagni for a considera- 
ble time, for examples similar to those which I had 
observed, I found one which I wish to relate.* 

A country woman, about fifty years of age, was af- 
fected at intervals with dyspnoea, accompanied with 
constriction of the chest. The pulse was hard, and 
all the arteries wCTe in such a state of agitation, that 
we could easily perceive their alternate motion, in 
the hands, in the temples and in the neck. When 
this woman was much affected with difficulty of re- 
spiration, she came to the hospital, where she was re- 
lieved by full bleeding. She had passed four years 
in this state, when she was suddenly attacked with 
pain in the stomach, and died in twenty-four hours. 

Examination of the Body. — The parietes of the 
left side of the heart were much thicker than in the 
natural state; while, in the right side, they were 
somewhat thinner. In the mean time, the aorta, the 
ventricles and pulmonary artery, ivere not in the least 
dilated. The valves of the aorta were somewhat in- 
durated, and yellow plicse were observed in different 
portions of the aorta, which announced the commence- 
ment of ossification; the carotids, and subclavians at 
the division of their branches were also more dilated 
than natural. 

The stomach presented several points of ulcera- 
tion, which, although of recent appearance, present- 

* Sec Epist. 29, Art. 20. 



DISEASES OF THE HEART. 317 

ed already a gangrenous black colour : numerous ero- 
sions were also observed on the oesophagus. 

This case, coming from a physician of such great 
authority , confirms, in the most happy manner, the 
numerous cases we have collected of simple hyper- 
trophy, or with a natural state of the cavity of the 
left ventricle. * 

€ase LXXXIV. 

Simple Hypertrophy of the right Ventricle; Hypertrophy % 
with Dilatation of the Corresponding 'Auricle; Contrac- 
tion of the left Auriculo-ventricular Orifice. 

Elizabeth Lassolle, thirty years of age, of a san- 
guine temperament, and very corpulent, had suffered 
from impaired health for three years, when she en- 
tered the Cochin hospital, on the 12th of December, 
1818. 

From the beginning, she had complained of slight 
dyspnoea, and, occasionally, transient palpitations; 
repeated catarrhal affections increased the difficulty 
of respiration, and produced a sense of suffocation 
very distinctly marked. 

This patient complained of violent headach, and, 
frequently, of a sense of hot vapour, which seemed to 
rise from the chest towards the head : the palpitations 
were renewed more frequently, and assumed some- 
what x)f a periodical character. 

We regarded this affection as nervous, and confined 
the treatment to a mild regimen, and a few antispas- 
modics. The symptoms ceased from time to time; 

* This case should be classed among those which relate to simple hyper- 
trophy of the left ventricle. 



318 DISEASES OF THE HEART. 

and the longer intermissions gave some hopes of a 
partial cure. 

The symptoms we are about to mention occurred 
about a month before she entered the hospital. 

She was rather corpulent, and had a bluish com- 
plexion; the eyes were slightly injected; the pulsa- 
tions of the carotids were considerably developed; 
the chest was quite loaded with fat, and did not al- 
low us to make any satisfactory diagnosis by percus- 
sion; the superior and inferior extremities were (Ede- 
matous, and depressions with the finger were made 
with considerable difficulty: the vertical position had 
become indispensable. 

Respiration was painful, short and precipitious; 
the palpitations were frequent; the pulsations of the 
heart were felt as far as the right side of the chest: 
these pulsations were soft; they were neither dry nor 
detached. The least compression of the chest pro- 
duced greater dyspnoea; the cough was infrequent, 
and accompanied by mucous expectoration; the pulse 
was low; the dilatation of the parietes seemed to be 
made with difficulty: the pulsations had neither the 
force nor the v vibration so common in hypertrophy. 

The abdomen was pliable, and not in the least pain- 
ful to the touch. 

The patient reclined her head almost constantly 
upon the chest; sometimes it was thrown backwards, 
with force, accompanied with groans and sighs; the 
arms were crossed over the chest, and this condition 
was continued night and day. 

The symptoms continued the following days with 
the same intensity. Several bloody striae coloured 
the matter expectorated; the palpitations and pulsa- 



DISEASES OF THE HEART. 319 

tions of the heart diminished, now and then, without 
any considerable relief to the patient. 

Finally, the symptoms augmented more and more; 
the sputa were more frequent and bloody, and the 
patient died on the 20th of December, at half past 
eleven o'clock, nine days after entrance. 

Inspection of the Body. — The chest contains a 
small quantity of serum; the lungs have formed ad- 
hesions, and these adhesions are old and well organ- 
ized. The texture of the lungs will scarcely allow 
of any blood to escape: they are soft and crepitant: 
we observe only on the inferior lobe of each, two or 
three portions which are hard and swollen. The 
pleura, near the adhesions, is healthy. The pericar- 
dium is healthy and transparent and contains only a 
small portion of serum. The heart is somewhat larger 
than natural, and loaded with a considerable quanti- 
ty of fat: the capacity of the right auricle is much 
increased, and its fleshy fasciculi more distinct than 
in the natural state; the parietes of the right ventri- 
cle, which is nearly of the natural size, are much 
thicker, and its columnar more developed than in the 
natural state. 

The right auriculo-ventricular orifice is free; the 
tricuspid valve presents several spots of induration: 
it is thickened, and of a yellow colour : the tendinous 
fillets attached to it are shorter than in the natural 
state. The orifice of the pulmonary artery offers 
nothing peculiar; the same may be said of the left 
ventricle, but the left auriculo-ventricular orifice is 
much altered. The opening which intercepts the 
two free edges of the mitral valve is very small : it is 
more than four lines and a half in its greatest diame- 



320 ' DISEASES OF THE HEART. 

ter, and in the smallest a Kne and a half ; the two 
extremities of its free edges are united, and blended 
with each other: the cords attached to it are matted 
together, and very short. The valve is thickened, 
fibrocartilaginous, strewed with numerous minute 
grains, forming small layers of variable density, and 
several small insulated nipples : it is of a pale yellow 
colour. The abdomen contains some serum. The 
mucous membrane of the stomach is very red, and its 
follicles are developed : that of the duodenum is of a 
rose red; that of the small intestine is red and thick- 
ened; lastly, that of the large intestines is redder and 
more inflamed. 

In this case, the phenomena of the contraction of 
the orifices of the heart predominate. We have oc- 
cupied ourselves with these too much in detail else- 
where, to return to them here. 



II.— ECCENTRIC HYPERTROPHY, WITH 
DILATATION. 

Case LXXXV. 

Hypertrophy of the Right Ventriele, with Dilatation of 

its Cavity. 

James Lauriot, sixty -four years of age, rope-ma- 
ker, was carried to the hospital Cochin the 29th of 
November, 1813, in a state which did not permit 
him to give an account of his disease. Those who 
accompanied him could give us no other informa- 
tion, excepting that he had been indisposed for two 



DISEASES OF THE HEART. 321 

years, and that he had continued to work till with- 
in three weeks. This man had expressed himself 
with difficulty, spoke in a low voice, had some dif- 
culty in arranging his ideas, and he at times fell 
into a species of delirium. His face, his ears, and 
his neck were of a very deep violet blue; respiration 
was laborious; the pulse weak, and rather frequent: 
we, could with great difficulty perceive the pulsa- 
tions of the heart; the lower extremities were infil- 
trated. This patient died the third day after he en- 
tered the hospital. 

Inspection of the Body. — The heart was much 
larger than in the natural state : the right auricle had 
rather greater capacity than natural; its parietes were 
a little thickened; the cavity of the ventricle of the 
same side was considerably enlarged : its walls were 
very firm, of a vermilion red colour, and at least dou- 
ble the natural size. The left ventricle offered no- 
thing peculiar, only its walls were flabby; the left 
auricle and all the valves were healthy. The valve 
of the foramen ovale was much relaxed, and very 
thin. 

The lungs were healthy. 

The abdomen contained about a pint of serum. 

Case LXXXVI. 

Aneurismal Hypertrophy of the Right Ventricle. 

A thrasher, seventy years of age, of a robust and 
sanguine temperament, was frequently troubled with 
hemorrhage from the nose, until he was twenty-five 
years of age: from this period, until forty, he was 
bled once or twice every year. At sixty years of 

41 



322 DISEASES OF THE HEART. 

age, he began to suffer from the pulsations of the 
heart, which gradually increased, as well as the ca- 
tarrh with which they were accompanied. In the 
mean time, the dyspnoea became considerable, and 
the inferior extremities were infiltrated; the patient 
left the department of the Seine-et-Oise, where he 
was born, to go to Paris. After having travelled 
three leagues on foot, he was taken with faintness, 
which continued nearly an hour; he again travelled 
on foot, the next day, about two leagues. Having 
arrived at Saint-Denys, he was obliged to take a car- 
riage, and spit blood the whole day. The next day, 
the 9th of April, 1810 ; he was received at the Co- 
chin hospital. His face was livid, and slightly yel- 
low; the lips were entirely violet; the lower limbs 
were infiltrated; the pulsations of the heart were 
strongly developed, although the weakness was ex- 
treme, and the pulse frequent, without either vibra- 
tion or irregularity: the dyspnoea, cough, and expec- 
toration of blood continued. On the 12th of April 
the pulse was insensible. On the 14th, oedema had 
invaded the right arm : the patient died the same day. 
Inspection of the Body. — About a pound of serum 
in the right pleura; lungs healthy. Heart filled with 
clotted blood, and at least double the natural size. 
The two auricles were distended, but offered nothing 
peculiar in other respects; the cavity of the right 
ventricle was nearly three times as large as in the 
natural state : its walls were dense, compact, and firm, 
and as thick as those of the left ventricle in the ordi- 
nary state. The latter was only of the natural size; 
its walls were somewhat thin, and contrasted with 
those of the right ventricle by their softness and flac- 



DISEASES OF THE HEART. 323 

eidity. The orifices were free. The mucous mem- 
brane of the stomach was of a deep red colour, al- 
most brown; the liver was of a yellow colour, striped 
with small black spots. , 



III— CONCENTRIC HYPERTROPHY, WITH 
CONTRACTION OF THE CAVITY. 

Case LXXXVIL 

Hypertrophy of the Right Ventricle, with a considerably 
diminished Cavity; Membranous Septum at the Orifice 
of the Pulmonary Artery; Persistence of the Foramen 
Ovale; Abscess and Softening of the Brain, 8?c. 

Marie Gabrielle Vilain had exhibited, from her 
earliest infancy, something unusual in her physiog- 
nomy. Whenever she took more than common ex- 
ercise, her face became discoloured of a violet hue : 
her respiration, which was habitually embarrassed, 
became so in a very high degree upon going up stairs. 
At forty-seven years of age, she ceased to menstru- 
ate, and began to complain of palpitations accompa- 
nied with acute pain in the precordial region : she 
often stopped to feel her heart beat, and at those 
times would say that she would soon die. Finally, 
her lips and face became so blue, even when she 
walked slowly, that she was fearful of being seen in 
the streets. She was subject to copious nasal hemor- 
rhages, one of which was frightful by its quantity 
and duration. She frequently experienced cramps 
in the limbs. Her constitution, farthermore, had al- 
ways been somewhat feeble; her stature was but lit- 



324 DISEASES OF THE HEART. 

tie developed. She remained unmarried, and led a 
regular life. She had arrived at the age of fifty-se- 
ven, when, on the 1st of July, 1821, towards noon, 
she complained to her sister of something like cramp 
in the left hand and foot. Soon afterwards, she ex- 
perienced great difficulty in moving the limbs; and, 
at length, entirely lost the power of motion and sen- 
sation of the whole of that side of the body; retain- 
ing, however, her rational faculties, and even the 
use of speech. The third day after these accidents, 
she entered the hospital Cochin, in the following 
state: expression animated, face of a violet red co- 
lour, lips blue, eyes projecting and brilliant; orthop- 
nea; pulse small, easily depressed in the left arm, 
hard and rather strong in the right; paralysis of the 
left side complete. (Arnica, haustus. aether.) 

During the night the paralyzed limbs were affect- 
ed with convulsions, like those produced by the nux 
vomica. At the same time, the respiration became 
more laborious, the face more animated, the eyes 
more brilliant; the lips presented a rose colour; the 
pulsations of the heart were tumultuous. On apply- 
ing the hand to the precordial region, we perceived 
a species of vibratory tremor. (Fifteen leeches to the 
anus; digitalis.) All these symptoms were promptly 
relieved, and were not accompanied with any of im- 
portance. The fourth day, at the visit, M. Bertin 
bled her in the arm: the day was tolerably tranquil. 
From the fifth to the twelfth day, she had many ac- 
cessions similar to the preceding, but not so long, nor 
so violent. Finally, the twelfth day, about noon, the 
patient suddenly lost her senses. Face animated; 
eyes extremely brilliant, and projecting; convulsive 



DISEASES OF THE HEART. 325 

agitation; dilatation of the pupil: respiration more 
and more impeded; universal paralysis; pulsations of 
the heart and the carotids stronger and more fre- 
quent. 

At the moment of her admission, we bled in the 
arm; after which, the patient could move the right 
arm a little: she even seemed to know what was said 
to her. But this improvement was only momentary: 
the symptoms, on the contrary, were aggravated. 
The patient died the next day; being the thirteenth 
day since the development of the cerebral affection. 
Inspection of the Body* — 1st. The heart was ex- 
tremely large; it weighed twelve ounces, while that of 
another woman, examined at the same time, weighed 
only four. The right auricle was much developed, 
and contained several ounces of blood. An opening 
resulting from a defective obliteration of the foramen 
ovale, about four lines in diameter, a communica- 
tion between the two auricles: the right auriculo- 
ventricular orifice was narrow; the cavity of the 
corresponding ventricle was contracted, and might 
contain a pigeon's egg; its parietes varied in thick- 
ness from eleven to sixteen lines; the valves were 
small, but their cordfe tendinese were strong, and ap- 
peared to be enveloped in a prolongation of the fleshy 
substance. The orifice of the pulmonary artery of- 
fered a horizontal septum, convex on the side of the 
lung, concave on the side of the ventricle; having an 
opening in its centre of two lines and a half in dia- 
meter, perfectly circular. This species of hymen 
had three small folds or wrinkles on its convex side; 
but we could not observe on either of its surfaces any 

♦See Plate Til 



326 DISEASES OF THE HEART. 

vestiges to indicate the division of its three valves. 
Beyond this septum the pulmonary artery presented 
nothing peculiar: the left auricle, nearly of the com- 
mon size, presented the orifice of the foramen ovale, 
above described; the left ventricle was larger and its 
parietes thicker than natural; the aorta was strewed 
with osseous and cartilaginous plicae; the passage of 
the artery was obliterated. 2. The anterior lobe of 
the right hemisphere of the brain contained an en- 
cysted abscess; around the soft and vascular mem- 
brane which contained the pus, the cerebral sub- 
stance offered a deep red colour, which became 
fainter in proportion to the distance from the depo- 
site, and afterwards assumed a yellow tint; the sub- 
stance, in that situation, was evidently softened. 
Under the pia mater we found here and there a pel- 
licular or albuminous matter, the consistence of which 
in some points was sufficiently great. 

This case is very important in many respects, and 
presents us with an arrangement of the orifice of the 
pulmonary artery so peculiar, that the annals of sci- 
ence can hardly furnish a similar example: we can 
only find one case, from the seventeenth letter of 
Morgagni which bears any resemblance to it. How- 
ever, between the case of Morgagni and the present, 
there are peculiarities, which every one may per- 
ceive without difficulty after having read the passage 
in which he describes the morbid structure of the 
ventriculo-pulmonary orifice. The description is as 
follows: " Sigmoides autem, quae pulmonaris arte- 
risa ostio prseficiuntur, ad basim quidem erant se- 
cundum naturam; sed parte superiore cartilagineae 
videbantur, quin exiguum ossis pustulum jam habe- 



DISEASES OF THE HEART, 327 

bant : erautque ea parte sic inter se colligate, ut vix 
foramen relinquerent, lente non majus, per quod san- 
guis exiret; erant autem ad illud foramen qusedam 
exiguae productiones carneo-membranos3&, ea ratione 
collocate, ut valvularum vices supplere possent, egre- 
dienti sanguini cedendo, regressino, autem obitando.. 
(De Sedibus. et Cans. Morb., torn. ii. page 525 and 
526, now edit, curante F. Chaussier.) 

This case presents us with a striking example of 
the complication so frequently met with in the vari- 
ous affections of the heart; in it we observe a pheno- 
menon which at first sight appears very extraordina- 
ry, namely, the constriction of the right ventricle : 
it would appear, on the contrary, when we take into 
view the orifice of the pulmonary artery, that the 
ventricle ought to have been dilated. 

In the mean time we can account, at least to a cer- 
tain extent, for their anomaly, when we reflect, that, 
by means of the foramen ovale, the portion of the 
blood destined to the right ventricle, would pass di- 
rectly into the left auricle : this ventricle, then, in- 
stead of dilating, would collapse so as to adapt itself 
to the small quantity of blood entering it. But how 
are we to explain the enormous thickening of this 
ventricle? We should say, undoubtedly, that the 
constant resistance which it is obliged to overcome 
to force the blood into the pulmonary artery, was 
sufficient to determine the hypertrophy, by forcing 
it to more powerful contraction. But this explana- 
tion supposes that the quantity of blood which the 
ventricle receives is not proportionate to the small- 
ness of the passage through which it should pass into 
the lungs; and we shall presently see that this hypo- 



328 DISEASES OF THE HEART. 

thesis is hardly admissible, since the ventricle, in- 
stead of being dilated, was, on the contrary, con- 
tracted; which we have explained by supposing that 
a considerable portion of the column of blood, coming 
from the vena cava, flows into the left auricle, through 
the foramen ovale. As for ourselves, if we ventured 
to propose at this moment an explanation, we should 
say that the hypertrophy of the right ventricle might 
have had, for one of its causes, the introduction of a 
certain quantity of blood from the left auricle into 
the cavity of the ventricle. We may conceive that 
the presence of this red, arterial, oxygenated red 
blood in the interior of the right ventricle, and its 
contact with the walls of this organ to which it had 
not been accustomed, ought to excite a kind of nu- 
trient irritation, which, acting from without inwards, 
should at length determine this form of hypertrophy, 
which is developed, as it were, at the expense of the 
cavity, and which we have, for that reason, called 
concentric. 

Case LXXXVIIL 

Hypertrophy of the Left Auricle; Interventricular Sep- 
tum and Columns of the Eight Ventricle , with En- 
largement of the Left Cavities; Contraction, or rather 
Disappearance of the Cavity of the Right Ventricle, 
and Softening of the Parietes of the Left, a little thick- 
ened towards the Jlpex. 

The patient, named Chenet, thirty-seven years of 
age, had begun to experience in the course of his 
thirty-second year, palpitations, somewhat violent, 
succeeding rheumatic pains : two bleedings in the 
arm removed this accidentj nevertheless, he could 



DISEASES OF THE HEART. 329 

not from that time take the least exercise, without 
being out of breath. Having been obliged to make 
rather a long journey, he was taken, on his return, 
with a febrile disorder, cough and slight palpitation. 
A physician directed him to take an emetic, which 
produced some relief at the time; but, some days af- 
ter, he was affected with somewhat acute pain in the 
chest, with cough and expectoration of blood. These 
symptoms continued for four or five days; some slight 
palpitations again occurred; they became more vio- 
lent soon after, and he determined to enter the hos- 
pital Cochin, where he presented the following con- 
dition : face slightly swollen, of a violet red colour; 
skin, in general, soft and pale; legs a little infiltrated; 
tongue reddish on the edges; cough frequent; respi- 
ration difficult, threatening suffocation in the hori- 
zontal posture. The attempts which the patient made 
to cough occasioned acute pain in the whole chest, 
and more particularly in the back : the expectoration 
was abundant, frothy, and liquid; the pulse full, de- 
veloped and vibrating; the pulsations of the heart 
were violent, and even felt in almost the whole ex- 
tent of the chest. 

A single blood-letting produced much relief. The 
next day the pain in the chest had diminished, and 
the palpitations were less frequent; the expectora- 
tion ceased to be bloody; but the pulse preserved a 
slight degree of vibration. This state was sustained 
for seven or eight days: the infiltration of the lower 
limbs was removed; his sleep was tolerably good at 
this time, and the secretion of urine abundant; but 
the same symptoms having begun to return, about ten 

42 



330 DISEASES OF THE HEART. 

days after the first bleeding, a second again procured 
some relief for several days. 

The 17th of November, in the morning, infiltra- 
tion of the limbs reappeared; the hand and arm 
were, for the first time, infiltrated; the face was 
but slightly coloured, but the lips were a little of a 
violet colour; the pulse was small and linear, fre- 
quent and always a little vibrating. All the symp- 
toms exacerbated towards six o'clock in the evening; 
respiration became more and more oppressed, acce- 
lerated and rattling, the face swollen and violet co- 
loured, the pulse hard and frequent: wc applied a 
large blister to the chest, and prescribed a potion 
with ether and kermes. 

The patient expired on the 28th, in the morning. 
Inspection of the Body. — The right thoracic ca- 
vity contained nearly half a pint of turbid serum, 
strewed with albuminous flocculi : the lung of this 
side was healthy and free from all adhesion; the left 
lung was adherent at all points with the adjoining 
parts; its adhesions, especially with the pericardium, 
appeared of very long standing; its texture was hepa- 
tised; the pericardium adhered strongly to the heart, 
especially at the anterior surface; the heart was very 
large, of a rounded form, and did not present the least 
appearance of the apex: the left auricle was enor- 
mously dilated, and its walls three lines in thickness; 
the left ventricle had undergone such a dilatation, 
and its cavity was so much enlarged, that it would 
probably contain eight ounces of fluid; but the pari- 
etes did not present any thickening, except towards 
the inferior portion and towards the apex; they were 
soft, and easily torn; the interventricular septum was 



DISEASES OF THE HEART. 331 

more than an inch thick in almost the whole of its 
extent; its texture was much firmer than the rest of 
the parietes; the right auricle was in the natural 
state, but the ventricle of that side was, to use the 
expression, atrophied, and constituted at least a fifth 
part of the left ventricle. The fleshy columnar were 
developed to nearly the size of a writing quill, and 
had contracted such adhesions between each other, 
that they filled the cavity of the ventricle, so that 
during life the blood could only permeate through 
their meshes. The mitral valve, at its adherent edge, 
presented a cartilaginous state; the aortic valve of- 
fered a similar degeneration at its middle part. 

This case is very curious in relation to anatomy. 
We are not acquainted with a single fact of any simi- 
lar disposition of the cavity and fleshy columns of the 
right ventricle. It is a singular circumstance, that 
the hypertrophy of these columns coincided with an 
atrophy of the ventricle itself, which was scarcely a 
fifth part of the size of the left. 



SECTION III. 
HYPERTROPHY OF THE AURICLES. 

That we may not multiply cases unnecessarily, we 
shall not relate, in this place, any of hypertrophy of 
the auricles. This disease hardly ever exists sim- 
ply, that is to say, distinctly from every other le- 
sion of the other parts of the heart : we have given 
examples in many of the preceding cases. (See Nos. 



332 DISEASES OF THE HEART. 

28, 29, 37, 38, 47, 49, 50, 51, 56, 62, 75, 79, 80, 
84, 85.) We need only repeat, here, that we have 
observed hypertrophy of the auricles under the tri- 
ple form noticed when speaking of that of the ven- 
tricles; but we ought to avow, that the anturismal 
form, or with dilatation, is incomparably more fre- 
quent than the other two. Several pathologists, also, 
and among others M. Laennec, assure us that they 
never met with hypertrophy of the auricles, not 
complicated with dilatation.* 



SECTION IV. 

SIMULTANEOUS HYPERTROPHY OF SEVERAL 
CAVITIES, OR OF ALL THE CAVITIES OF THE 
HEART 

We shall give examples of hypertrophy of each of 
the cavities of the heart: observation proves how 
rarely we meet with this disease affecting only one of 
the cavities of the heart. More frequently, several 
cavities are hypertrophied at the same time, and the 
form of the hypertrophy varies also in each of them. 
It would take up too much room to offer new exam- 
ples of all the complications and combinations of this 
disease: we shall proceed, however, to relate two 
other cases, one of which will exhibit, at the same 
time, a hypertrophy of both ventricles, and the other 
an aneurismal hypertrophy of all the cavities of the 
heart, with dilatation and chronic inflammation of 
the walls of the aorta. 

* Be 1'Auscult. Mediate, torn. ii. pag*e 280, 281 



DISEASES OF THE HEART. 333 



Case LXXXIX. 

Hypertrophy of both Ventricles, with diminution of their 

Cavities. 

Catherine Moreau, fifty years of age, of a lympha- 
tic constitution, had frequently taken cold in her 
youth; at a more advanced age, she experienced al- 
most constantly a dry cough, a fixed and deep pain 
at the left inferior part of the sternum: phenomena 
which are too frequently exasperated by domestic 
disappointment. Finally, a new catarrhal affection 
supervened, for which the patient entered the hos- 
pital Cochin the 25th of March, 1814. Her face 
was then slightly swollen, the eyes projecting, the 
lips discoloured, and the colour of the skin, in gene- 
ral, a pale yellow; there was a deep pain and sense 
of weight in the precordial region; the chest re- 
sounded sufficiently well; the pulsations of the heart, 
irregular and tumultuous, were not in harmony with 
the pulse; this absence of harmony, however, was not 
always constant; to precipitous and excessive palpi- 
tations, succeeded strong and frequent but regular 
pulsations, which were pretty nearly in harmony 
with those of the pulse; the pulse, most commonly 
small and yielding, presented, in the moments of ex- 
acerbation, hardness, tension and vibration; but, in a 
short time, resumed its first character; the difficulty 
of respiration was extreme, and the slightest exercise 
produced an .insupportable oppression; the horizon- 
tal position was impossible; syncope occurred rather 
frequently. 

This state continued, without any marked change. 



334 DISEASES OF THE HEART. 

until the 5th of April; but, in the evening of the 
same day, the anxiety, palpitations and dyspnoea 
augmented considerably. After a repast rather more 
full, and a walk a little longer and more fatiguing 
than usual, the face is slightly coloured; the eyes 
have become red, rather strongly injected, and weep- 
ing; the lips are pale, and somewhat livid; insupport- 
able coldness has affected the extremities; a sense 
of strangulation has occurred, and the patient, after 
some efforts to cough, expectorates vermilion-coloured 
blood. 

The 7th we perceived for the first time that the 
legs were infiltrated. The following days, the infil- 
tration gradually increased, but the palpitations dimi- 
nished in force and frequency. 

The 25th the infiltration invaded the upper extre- 
mities and face; sleep has become impossible; the 
palpitations have resumed their former intensity, 
and the patient fears, at every moment, that she shall 
die of suffocation. The evening of the same day, the 
sputa were small in quantity, but tinged with blood; 
respiration is very short and stertorous : the patient 
fell into a comatose state, agony occurred, and the 
patient expired the next day, the 26th. 

Inspection of the Body. — The body is enormously 
infiltrated: the muscles pale; the chest contains a 
large quantity of citrine coloured serum; the lungs 
and the pleura do not offer any alteration; the peri- 
cardium contains nearly two pints of a fluid perfect- 
ly resembling that in the chest; the heart did not 
appear much larger than in the natural state. The 
superior and external side of the right ventricle is 
loaded with soft yielding fat; the right auricle offers 



DISEASES OF THE HEART, 335 

a cavity double the natural size; and the thickness of 
its walls is nearly triple. The thickness of the pa- 
rietes of the right ventricle is more than doubled, 
and this augmentation of nutrition is made at the ex- 
pense of the cavity which is much contracted; the 
walls of the left ventricle are also much thicker than 
in the natural state : the cavity offers a contraction 
still more considerable than that of the right; the 
membrane which covers this cavity is hard, glossy, 
and fibro-cartilaginous; the mitral valve participates 
in this affection, and presents even some points of 
bony matter. The left auricle has nothing peculiar; 
the other viscera are in the natural state. 

In this interesting case, hypertrophy had formed 
in both the ventricles, and at the expense of their 
cavities. You will remark that the internal mem- 
brane of the left ventricle is hard, and fibro-cartila- 
ginous, which sufficiently indicates chronic phleg- 
masia, and you will comprehend, from this case, how 
the nutritive augmentation takes place concentrical- 
ly. The obstacle to the circulation, in this case, was 
so considerable, that we ought not to be astonished 
with the extreme anxiety, suffocation, and infiltra- 
tion which we observed during life. 

Case XC. 

Hypertrophy and Dilatation of all the Cavities of the 
Heart; Aneurism and Ossification of the Heart. 

Delaire Marie Desiree, fifty-two years of age, of a 
melancholic temperament, had suffered, at the com- 
mencement of marriage, great depression of mind. 
In a short time, a deep-seated pain occurred in the 



336 DISEASES OF THE HEART. 

precordial region, with a sensation of weight and suf- 
focation, and slight palpitations. These symptoms 
having increased, she determined to go to the hospi- 
tal Cochin, the 29th of November, 1816. 

At that time her face was pale and swollen, respi- 
ration short, stertorous, and panting; the least exer- 
cise occasioned dyspnoea nearly to suffocation, and 
increased the palpitations, the approach of night, or 
even the slightest contrarieties excited them; the 
pulsations of the heart were even sometimes so vio- 
lent that the patient heard them, and they even hin- 
dered her from going to sleep. 

The abdomen was a little swollen, and at times 
painful; the pulse discovered great variations, some- 
times it was concentrated, but more frequently hard, 
tense and vibrating. 

We prescribed blood-letting in the arm, and ten 
leeches to the left side of the chest. These means 
procured momentary relief; but the symptoms were 
soon renewed with the same intensity. In about fif- 
teen days, the pulsations of Lhe arteries became 
stronger, and the oppression more considerable, the 
respiration shorter, and even stertorous : finally, the 
expression was lost; the eyes, the lips, and the nose 
took on a violet tint, hiccough occurred, and did not 
cease until death, which happened the day after its 
appearance. 

Inspection of the Body. — The lungs were perfect- 
ly healthy; the pericardium contained but little se- 
rum; the heart appeared of twice the natural size; 
the left ventricle and auricle were nearly double the 
common thickness and capacity; the mitral valves 
were healthy, excepting that they exhibited some 



DISEASES OF THE HEART. 337 

bony points. The right cavities of the heart were 
also much thicker and more capacious than in the na- 
tural state; the aorta, dilated at its origin, and still 
more at its curvature, presented ossific laminae in va- 
rious points of its extent; but especially near the 
heart; the external coats offered branches correspond- 
ing to the rupture of the internal and middle coats. 



ARTICLE I. 

GENERAL HISTORY OF HYPERTROPHY, OR NUTRITIVE 
IRRITATION OF THE HEART. 



SECTION L 

ANATOMY OF HYPERTROPHY OF THE HEART. 

When all the cavities of the heart are affected at 
the same time with hypertrophy, especially if they 
are at the same time dilated, the heart presents some- 
times a prodigious volume, so great as to be even 
three or four times the size of the fist of the indivi- 
dual; its position and its form are then changed: it is 
commonly situated transversely, or almost in the ca- 
vity of the chest, of which it occupies a large por- 
tion; its form is in general rounded; its apex is obtuse 
and almost effaced; in cases of considerable dilatation 
it has, as M. Laennec observes, the form of & pouch; 
the muscular substance of the heart is of a red ver- 
milion colour, and good consistence; the thickness of 

43 



338 DISEASES OF THE HEART. 

the walls may be double, triple, and even quadruple 
that which constitutes the normal state; the^coronary 
arteries are developed; sometimes one of them is in- 
comparably more voluminous than the other. 

Observation enables us to establish three distinct 
forms of hypertrophy. 

The first form is that in which the cavities of the 
heart preserve their natural capacity, at the same time 
that their parietes are more or less thickened: this is 
simple hypertrophy. 

In the second form the cavities are dilated and the 
walls thickened : this might be called eccentric, or 
aneurismal hypertrophy. 

Lastly, the third form is characterized by thick- 
ening of the walls coinciding with more or less con- 
traction of the cavities: to this we have given the 
name of concentric hypertrophy. 

Aneurismal hypertrophy may be distinguished into 
two different species of aneurismal hypertrophy, one 
in which the parietes are thickened; and another in 
which they preserve their natural thickness, so that 
the hypertrophy is found to take place according to 
the extent and the circumference, or according to the 
surface. 

Hypertrophy is very far from being uniform in the 
walls of the heart, in the septum and the fleshy co- 
lumns: it varies in the ventricles and the auricles, 
in the left and the right ventricle. 

Hypertrophy of the ventricles not unfrequently 
proceeds according to the natural course of nutrition, 
that is to say the thickness, more considerable at the 
base and at the middle part, gradually diminishes to- 
wards the apex. Nevertheless, in concentric by- 



DISEASES OF THE HEART. 339 

pertrophy, the thickness is nearly the same at the 
apex as at the base. We have seen in analogous 
cases the left ventricle globular or spheroid, present- 
ing an equal thickness, of nine or ten lines, through- 
out its whole extent. 

In some circumstances the hypertrophy, more 
marked at the middle part, gradually diminishes to- 
wards the apex, and even towards the base; the thick- 
ness of the parietes may extend to fifteen lines even 
beyond. According to M. Laennec, " the absolute 
thickness of the parietes of the right ventricle is not, 
in any case, very considerable: he has never found 
it more than four or five lines. "# Nevertheless, in 
our 88th case we may observe that this thickness is 
from eleven to sixteen lines. M. Louis has recently 
met with a similar case, which he has published in 
the Archives de Medecine. 

Finally, it sometimes happens that we find in the 
same ventricle, one portion dilated and, at the same 
time, hypertrophied, and another contracted and hy- 
pertrophied; at other times one portion is thinned, 
whilst another is thickened. These are mixed states 
of disease. A great difference is sometimes observed 
between the parietes of the ventricles, especially 
those of the right, and the columnar carneae: these 
may be double or triple the natural size, while the 
parietes are not in the least, or but very little hyper- 
trophied; at other times the hypertrophy of the pa- 
rietes of the left ventricle seems to take place at the 
expense of the columnae, which are either entirely 
obliterated, or scarcely visible. In the cases of hy- 

* Auscult. Med., torn. ii. page 260, 



340 DISEASES OF THE HEART. 

pertrophy of the left ventricle, only that cavity ap- 
pears to constitute the entire heart, and the right 
ventricle seems to be only a sort of appendix to it, 
as if the left ventricle had been hypertrophied at the 
expense of the right. The hypertrophy of the left 
ventricle generally involves that of the septum. 
Sometimes, however, a hypertrophy of the interven- 
tricular septum is observed, distinct from any change 
in the surrounding parts. In an individual, whose 
case we have cited, the fleshy pillars of the right 
ventricle were so much thickened and interwoven 
that there was hardly any cavity, and the blood could 
only filtrate through the narrow intervals between 
them. (Case 89th.*) 

Hypertrophy affects not unfrequently both ven- 
tricles at the same time; it is not uncommon, howe- 
ver, to find them in the opposite state. When the 
right ventricle is thickened, for example, the left, 
less firm and less fleshy than natural, approaches to 
the normal state of the right ventricle, which would 
lead us to suppose that there was a kind of transposi- 
tion of organs in these cases. (Morgagni, Corvisart, 
&c.) Whichever may be the ventricle hypertro- 
phied, we may observe that the apex of the hyper- 
trophous ventricle descends lower than the other. 

We may observe in the auricles the three forms of 
hypertrophy which we have pointed out, but the 
most common is the aneurismal hypertrophy. The 
thickening is tolerably uniform in the whole extent 
of the walls; this uniformity is found more especially 
in the left auricle, which is owing, undoubtedly, to 

* Morgagni has noted a similar case. 



DISEASES OF THE HEART. 341 

the circumstance that, naturally, the thickness of 
the parietes of the left auricle is more uniform than 
that of the parietes of the right, which possesses 
more fleshy and more numerous columnar. The 
muscular fasciculi of the auricle conveying the vei- 
nous blood, are sometimes the exclusive seat of hy- 
pertrophy: the parietes, in their intervals, preserving 
the thickness which is natural to them. In some 
cases the walls of this auricle are so hypertrophied 
in every part, that they resemble those of the corre- 
sponding ventricle. 

The whole of this description refers to hypertro- 
phy exempt from complications; we should be care- 
ful not to confound with it the hardening or the soft- 
ening of the heart, which are changes of its nutri- 
tion, while the hypertrophy is only an augmentation 
of it. 



SECTION IL 

FORMATION OF HYPERTROPHY OF THE 
HEART 

Blanchard, Senac, Morgagni, Corvisart, and many 
others since them, have justly compared the hyper- 
trophy of the heart to the increase of nutrition, which 
takes place in all the organs, and particularly in the 
external muscles habitually submitted to undue ex- 
ercise, which causes the blood to flow in large quan- 
tity into their texture. When from any cause the 
blood is obstructed in its course, it accumulates in 
the cavities of the heart, and distends them: it enters 



342 DISEASES OF THE HEART. 

in too great quantity, and reverts upon the coronary 
arteries. The heart, irritated by the presence of 
this increased quantity of fluid, redoubles its ener- 
gies, struggles, as it were, with all its powers against 
the resistance which it meets with; but these violent 
exertions themselves have the effect to solicit a new 
afflux of blood into the texture of the organ; so that 
the effect soon begins to take part with the cause. 
Stimulated beyond measure, the heart augments in 
bulk and thickness, and acquires an energy of con- 
traction proportioned to the development of its hy- 
pertrophy. 

More voluminous and more fleshy than the right, 
the left ventricle, in contact also with a more quick- 
ened, irritating and nutritive blood, is naturally pre- 
disposed to hypertrophy, and we ought not to be sur- 
prised that this affection assumes its own choice of 
situation. The normal constitution of this ventricle 
is, strictly speaking, the first degree of hypertrophy. 
Although less subject to hypertrophy than the left 
ventricle, the right is, nevertheless, not entirely ex- 
empt from it : whenever this disease appears, it is so 
little compatible at the outset with the natural orga- 
nization of its ventricle, that authors (Morgagni and 
Corvisart among others) have thought themselves 
obliged, in order to explain it, to suppose a natural 
organic predisposition, to imagine a transposition of 
the ventricles. This is a convenient method of 
evading the difficulty; but, surely, to create such an 
hypothesis is not to resolve it. It is not probable 
that if the right ventricle be less frequently hyper- 
trophied than the left, it is owing, in a great measure, 
to the nature of the blood which fills it, and the in- 



DISEASES OF THE HEART. 343 

frequency of the lesions of the pulmonary orifice and 
its valves? 

If we were to suppose for a moment the presence 
of arterial blood in that ventricle, every thing else 
being equal, we should conceive that it was as sub- 
ject to hypertrophy as the left ventricle. Nature 
sometimes realizes the supposition we have already 
made. This is what happens in those cases where, 
either by means of the foramen ovale, or in some 
other analogous manner, the left cavities communi- 
cate with the right, from which it results that a cer- 
tain quantity of arterial blood is introduced into 
them. Hence, if we examine cases of this kind at- 
tentively, we shall see that they coincide with hy- 
pertrophy of the right ventricle. This is what took 
place, for example, in the patient, in the 88th case, 
where the hypertrophy of the right ventricle was 
truly enormous. M. Louis has observed a similar 
case, and almost all those which he has collected in 
his memoir on the communication of the right with 
the left cavities of the heart, tend to confirm our opi- 
nion on this mode of the formation of hypertrophy.* 
If the hypertrophy of the right ventricle take place 
according to the same process as that of the left, the 
same must also be the case with that of the auricles. 
It also occurs when, in consequence of a constriction 
of the orifices of the heart, too large a quantity of 
blood distends, stimulates, and irritates them, and 
causes them to assume a kind of nutritive excitation. 
In general, it is the cavity nearest the obstacle to 



* See this Memoir in the Arch. Gener. de Med., 12th Cahier, Decembre, 
1805. 



344 DISEASES OF THE HEART. 

the circulation which is hypertrophied or dilated; 
but it may happen, however, to be a cavity more re- 
mote; although all the other cavities of the heart may 
be successively affected with the lesion in question, 
so intimate are the reciprocal connexions which unite 
them. 

However it may be, it is evident that the blood is 
an indispensable element in the formation of hyper- 
trophy. Its presence is a necessary condition; but 
by what mechanism does the blood, that liquid flesh,* 
according to the happy expression of Bordeu, concur 
in the process of hyper trophication? What opera- 
tion of vital chemistry, what laws preside in the for- 
mation of hypertrophy? a problem which, evidently, 
does not admit of solution in the present state of phy- 
siology, and never will, until we have removed the 
veils which yet obscure our knowledge of the pro- 
cess of nutrition. 



SECTION III. 

OF THE CAUSES OF HYPERTROPHY OF THE 
HEART. 

Corvisart has presented, in his beautiful work, a 
truly frightful catalogue of all the causes proper to 
produce either hypertrophy or the other diseases of 

* The original expression, "chair coulant," is a beautiful illustration of 
the peculiar adaptation of the French language to express physical pheno- 
mena. Such examples continually occur, and will account, in a great mea- 
sure, for the superiority of the French Savanfes in almost every branch of 
natural history. C. W. C. 



DISEASES OF THE HEART. 345 

the heart. He divides them into hereditary, innate 
or accidental. It may be congenital, or acquired, 
primitive or consecutive; it may affect a concentric 
progress in its formation, or it may proceed in the 
opposite course.* Hypertrophy recognises for its 
immediate and proximate cause an irritation applied 
to the heart, of the same kind with those which Ma- 
randel, M. Cruveilhier, and others, have given the 
name of nutritive irritation. Too large a quantity 
of blood accumulated, either in the cavities or in the 
vessels of the heart, is the most common source of 
this irritation: consequently, all the causes capable of 
producing such an engorgement will be the real causes 
of hypertrophy : in this number we should reckon 
violent exercise of every description, exertions,! 
and all the professions which require it; the various 
passions, and especially those which vehemently aug- 
ment the energy of the contractions of the heart and 
cause them to palpitate with force. 

The influence of moral affections in the production 
of the organic diseases of the heart, is incontestably 
very powerful; but it would be to exaggerate a great 
deal, to attribute exclusively to the passions excited 

* According to the ingenious comparison of Burns, the process of the for- 
mation of hypertrophy, with dilatation, is similar to that by which the ute- 
rus, during pregnancy, becomes dilated, developed and thickened; but it is 
hardly possible to admit a perfect identity between these two phenomena, 
which, nevertheless, are, perhaps, not without some analogy. 

j- Whoever has reflected for a moment upon the manner in whicli the ef- 
forts of the heart take place, will not be astonished if they should often give 
rise to hypertrophy and aneurism of the heart. In fact, in every effort, but 
especially in those which are very considerable, the large vessels are vio- 
lently compressed, and the column of blood which they contain is forced 
back, the one portion towards the heart, and the other towards the capillary 
systems. 

44 



346 DISEASES OF THE HEART. 

by our revolution, the frequency of the diseases of the 
heart at that period. If they appeared at that time, 
and appear in the present day more common than 
ever, it is because the art of observing and discover- 
ing them has made more brilliant progress. 

The diseases, whether acute or chronic, of the re- 
spiratory organs, pneumonias, tubercles, hydrotho- 
rax, all those, in short, capable of producing an ob- 
struction to the circulation intermediate between the 
right and left cavities; the indurations and vegeta- 
tions of the valves of the heart; the contraction of the 
aorta; its aneurismal dilatations, and the ossifications 
of its membranes, are new causes of hypertrophy of 
the heart. We might say as much of the durations 
of the vertebral column, and of all those deformities 
which diminish the capacity of the chest, 



SECTION IV. 

OF THE INFLUENCE OF HYPERTROPHY OF THE 
VENTRICLES ON THE OTHER ORGANS, AND 
ESPECIALLY ON THE BRAIN AND LUNGS. 

Nothing is better demonstrated in physiology, in the 
present day, than the influence of the left heart on the 
circulation of the encephalon: we might, consequent- 
ly, advance a priori, that one of the- immediate con- 
sequences of hypertrophy of the left ventricle would 

* The greater number of those affected with gibbosity, are finally at- 
tacked with some disease of the heart. We might furnish numerous i 
for the support of this assertion. 






DISEASES OF THE HEART. 347 

be a predisposition to apoplexy, to encephalitis, and, in 
fact, to all the cerebral irritations. What reason leads 
us to foresee, observation confirms in the most positive 
manner. In fact, the greater number of patients, in 
whom we have been able to verify the existence of 
hypertrophy of the left ventricle, have presented 
symptoms of cerebral congestion, and many have even 
died of it. Three illustrious physicians, torn from 
science by frightful apoplexy, Malphigi, Cabarris, 
and Ramazzini were evidently affected with hyper- 
trophy of the left ventricle. M. Richerand has, 
therefore, with reason, established the following prin- 
ciple; that this affection is a predisposition more 
nearly allied to apoplexy than what is called the apo- 
plectic constitution itself. We might even add that, 
in general, persons who present the apoplectic con- 
stitution indicated by authors, are, at the same time, 
remarkable for the volume and thickness of their 
heart. 

There is one circumstance which may weaken, to a 
certain point, the too powerful impulse of the hyper- 
trophied left ventricle on the circulating system of 
the encephalon, and this is the contraction of the com- 
mencement of the aorta. We may conceive, in fact, 
that this disposition offers a kind of resistance, which 
absorbs, if we may be allowed to say so, a part of the 
shock communicated by the ventricle to the column 
of blood directed towards the brain. We should not, 
however, after the example of some modern authors, 
whose authority is very respectable in other particu- 
lars, attribute to this cause an unlimited efficacy. 

For the same reason that hypertrophy of the left 
ventricle predisposes to apoplexy, it predisposes 



348 DISEASES OF THE HEART. 

equally to the other active hemorrhages. These pa- 
tients, also, are in general very subject to epistaxis, 
for example.* 

In having demonstrated the influence of hypertro- 
phy of the left ventricle on the brain, we have proved 
that of hypertrophy of the right ventricle upon the 
lung. Because, in the same manner as the encepha- 
lon receives directly the shock of the flow of blood 
which the left ventricle throws into the aorta, so the 
lungs receive immediately the impulsion communi- 
cated to the column of blood which the right ventri- 
cle projects into the pulmonary artery. Consequent- 
ly, when the parietes of that organ have augmented 
in thickness and energy, they impress on the pulmo- 
nary circulation a proportionate activity, overcoming 
at once the resistance of the vessels, and hence the 
hemorrhagies and pulmonary apoplexies, if we may 
so say, which take place after the same manner as 
in apoplexy, properly speaking, and in cases of hy- 
pertrophy of the aortic ventricle. It is to this cause 
we must refer the haemoptysis which we have ob- 
served in some of our patients. The hemorrhagic 
congestions alluded to are essentially active; we should 
not confound them with those which are produced 
by any obstruction to the circulation, as those which 
occur, for example, in cases of contraction of one or 

♦ As the vascular system of the eye is a dependence of that of the brain, 
the hypertrophy of the left ventricle produces an effect on that organ analo- 
gous to that produced on the encephalon: Hence the injected and brilliant 
state of the eye, and sometimes inflammation. Professor Ferta, of Bologne, 
has noticed watering of the eye as one of the effects of the diseases of the 
heart. Does there exist any relation between the phenomenon and the ossi- 
fication of the ophthalmic arteries, so frequently met with in cases of hyper- 
trophy of the left ventricle ? 



DISEASES OF THE HEART. 349 

more orifices of the heart. The first are arterial, if 
we may so speak, the second venous : the latter are 
the result of the stasis and reflux of the blood in the 
capillaries; the former are, on the contrary, produced 
by the too impetuous afflux of the blood in the capil- 
lary systems. We should be able to distinguish these 
frightful cerebral, pulmonary, or other hemorrhagies, 
and those sudden congestions of blood, from that sub- 
apoplectic state, or from that expectoration of dark 
coloured blood, or species of bloody sanies, which 
announces the deplorable death of those affected with 
great embarrassment of the circulation. 



SECTION V. 

OF THE SIGNS AND DIAGNOSIS OF HYPERTRO- 
PHY OF THE HEART. 

We have seen to what anatomical characters we 
must refer hypertrophy of the heart; but it is not 
enough to know the anatomical symptoms of a disease, 
symptoms which we can only obtain after death; it 
is necessary that we should know also the physiologi- 
cal signs, by means of which we are enabled during 
life to confirm the existence of hypertrophy. These 
symptoms are of two orders: some of them consist of 
the modification which the organ diseased has suf- 
fered in its action and in its functions; the others are 
the various lesions produced by the influence of the 
organ diseased on the other functions of the economy. 
The first, and most important, are the idiopathic 



350 DISEASES OF THE HEART. 

symptoms; the others we will call, if you please, the 
sympathetic or remote symptoms. 

A. Idiopathic Symptoms of Hypertrophy of the 
Heart. 

To discover these symptoms we must employ three 
of our senses: the sight, the touch and the hearing. 
These symptoms should be sought for in the modifi- 
cations which supervene in the impulsion, extent, 
sound, and rythm of the pulsations of the heart,* and 
are never well marked, excepting so far as the hy- 
pertrophy has attained a certain degree of develop- 
ment. 

1st. Symptoms funiislicd by the sight. — The mo- 
tions of the heart are visible in a greater or less ex- 
tent of the chest, according to the volume of the hy- 
pertrophy. — Sometimes the thorax is shaken as high 
up as the left clavicle, the epigastric region agitated, 
and the clothing or bed-clothes of the patient thrown 
upward. 

2d. Signs furnished by the touchy either imme- 
diate or mediate. — If the hand be applied over the 
precordial region, it is struck, and, as it were, rudely 
repelled, by strong, abrupt, diffuse pulsations; some- 
times perfectly detached and superficial, at other 
times deeper and more concentrated. It seems, in 
some cases, as if the whole of the heart struck the 
hand; whilst, in others, it presents only the apex. 
Sometimes a jarring tremor is felt in the thoracic pa- 



* It is evident that we ought to, explore the heart in its tranquil state, if 
we do not wish to expose ourselves to the risk of committing- errors of diag- 
nosis, always unfortunate for the patient, and frequently for the physician. 



DISEASES OF THE HEART. 351 

vietes for a great extent, and even in the posterior 
part of the chest. In some cases it seems as if the 
hand not only touched the pulsations of the heart, but 
also that it makes them heard, as if it answered the 
purpose of the stethoscope. If, instead of exploring 
the contractions of the heart with the hand, we ex- 
plore them with the cylinder, we shall obtain per- 
haps a still more precise idea of their impulsion. That 
instrument renders it very sensible, even when it es- 
capes the exploration of the hand : we have recog- 
nised hypertrophies by means of it, which we never 
should have been able to do in any other way. 

3d. Signs furnished by the hearing.— -We may 
distinguish them into those furnished by percussion, 
and those furnished by immediate or mediate auscul- 
tation. 

1st. If we strike on the precordial region it gives 
an obscure or flat sound, in an extent proportionate 
to that of the hypertrophy. By this simple mode of 
exploration, Corvisart says he has frequently ascer- 
tained with accuracy the size of the heart. We must 
acknowledge, however, that percussion is far from 
being a method so valuable and faithful as auscul- 
tation. 

2d. We might say that, in general, hypertrophy 
has the effect to weaken the intensity of the sound, 
which accompanies the pulsations of the heart. But 
it is important here to distinguish those cases in which 
the hypertrophy is simply accompanied with a con- 
traction or dilatation of the cavity. 

In the simple hypertrophy, the sound produced 
by the contractions of the heart is more dull and 
more profound than in the natural state : it is more 



352 DISEASES OF THE HEART. 

prolonged, because the duration of its contraction is 
augmented in consequence of the degree of hyper- 
trophy: it is seldom heard excepting in the precor- 
dial region itself. This sound is yet more obscure 
in hypertrophy with contraction of the cavity : it con- 
trasts with the force of the impulsion. Hypertrophy, 
with dilatation, is, on the contrary, characterized by 
the increased intensity of the sound of the pulsations 
of the heart; a phenomenon which depends upon the 
dilatation, and not the hypertrophy. In this case the 
contractions are sonorous and strong; they are propa- 
gated through a great extent of the chest, and are 
heard sometimes even at its posterior part, and, in 
fact, resemble the blows of a hammer. 

We can ascertain the rythm of the pulsations of the 
heart with equal precision, either by sight, touch, or 
hearing. But auscultation is a mode much more sure 
and exact than the other two, and hence the reason 
why we have deferred speaking of the varieties of 
this rythm until the present time. It is certain 
that hypertrophy, exempt from every complication, 
scarcely alters the rythm of the contractions of the 
heart; they preserve their regularity, and are, per- 
haps, a little more frequent than in the natural state. 
Nevertheless, as they are also more prolonged, it 
hence results that their number seldom exceeds that 
which constitutes the natural state. 

It is only at intervals that the pulsations of the 
heart become much more frequent and stronger than 
in the ordinary state. It is then that patients com- 
plain of what they call palpitations. Hypertrophy, 
in fact, disposes to that affection, which hardly ever 
fails to be developed, if the patients take somewhat 






DISEASES OF THE HEART. 353 

too violent exercise, or if they suffer more than com- 
mon moral emotions. When the intermissions and 
great irregularities of the contractions of the heart 
are observed in hypertrophy, it is because this coin- 
cides with other lesions, and among others with a 
contraction of the orifices, or an aneurism of the 
aorta. 

It is not sufficient to have pointed out the symp- 
toms which announce hypertrophy of the heart in 
general, it is necessary, also, that we investigate 
those which characterize the hypertrophy of each of 
the cavities of the heart in particular; a kind of diag- 
nosis which Corvisart has regarded as very uncertain, 
and even impossible, w r hich, however, in the present 
day, can be established in the most precise manner. 
But, before occupying ourselves with them, let us 
examine the second order of the symptoms of hyper- 
trophy.* 

B. — Sympathetic , general or common, symptoms of 

Authors. 

1st. Exploration of the circulation. — We have al- 
ready observed that persons affected with hypertro- 
phy of the heart, suffer at intervals more or less vio- 
lent and prolonged palpitations. The pulse presents 
many modifications relative to the form, degree, and 
complications of hypertrophy. The latter derange 
the proper pulse of hypertrophy so much that it can 
hardly be distinguished; we shall, therefore, make 

* Among the number of idiopathic, but doubtful symptoms, of hypertro- 
phy, we might mention the sensation of weight and oppression, which th« 
patients complain of in the precordial or diaphragmatic region. 

45 



354 DISEASES OF THE HEART. 

an abstract of them here. Now, in pure hypertro- 
phy, the pulse is in general regular, but harder and 
stronger than in the ordinary state. Is the hyper- 
trophy simple, without any dilatation of the cavity, 
or with dilatation not sufficient to have weakened the 
resilliency of the muscular fibres? the pulse is full, 
very distinct, free, tense and vibrating. 

In hypertrophy, with contraction of the cavity, 
the pulse preserves its hardness and stiffness, is but 
little developed, and somewhat compressed or em- 
barrassed. It is not necessary to observe that the 
examination of the pulse only furnishes the symptoms 
of the hypertrophy of the aortic ventricle, and is no 
resource in the diagnosis of the hypertrophy of the 
right ventricle. 

2d. Exploration of the respiration. — In general, 
respiration is little disturbed in pure and simple hy- 
pertrophy, moderately developed. But when the 
disease has greatly increased the size of the heart, so 
that it occupies a large part of the space destined for 
the lung, respiration is impeded in a very remarka- 
ble manner. In truth, in such cases, it is rare that 
there does not exist some other cause of dyspnoea, to 
which the hypertrophy itself is frequently consecu- 
tive. There is one form of hypertrophy which is 
calculated to induce considerable disturbance of re- 
spiration; we refer to that with contraction of the 
cavity. We may conceive, in fact, that when this 
is very considerable, the same phenomena must re- 
sult from it, which would, if one of the orifices of the 
heart had been contracted, (See the chapter on these 
contractions.) 



DISEASES OF THE HEART. 355 

3d. Exploration of locomotion and enervation. — 
Moderate hypertrophy, without complication, far 
from weakening these two functions, gives them 
greater energy. It is only in cases where the dis- 
ease, either by the form which it assumes, or by its 
enormous development, disturbs, in a remarkable 
manner, the circulation and respiration, that the mus- 
cular and nervous functions suffer a proportional 
weakness; as w r e have already explained when treat 
ing of the lesions of the valves. 

The picture we have drawn is far from perfectly 
resembling that of authors. But we can say, wit' 
truth, the symptoms of hypertrophy, or of active 
aneurism, commonly called general, have never been 
submitted to the test of physiological analysis, and on 
this subject, every author has committed grievous 
mistakes. Look into their works, and you will find 
that they enumerate as symptoms of hypertrophy, or 
active aneurism, dyspnoaa, suffocation, violet injec- 
tion of the face, swelling of the lips, and of all the 
venous capillaries in general, passive hemorrhages, 
and serous infiltration. This is, however, an error, 
a kind of physiological contradiction not easily ac- 
counted for; these symptoms evidently indicate an 
obstruction or embarrassment of the circulation : now 
how can we reconcile this difficulty of the circula- 
tion with hypertrophy and active aneurism of the 
heart? Far from interrupting the current of the cir- 
culation, this state of the heart, on the contrary, is 
evidently calculated to impress new energy upon the 
course of the blood. Can you suppose, in fact, that 
hypertrophy is capable of weakening the current of 
the circulation? You might as well say then that the 



356 DISEASES OF THE HEART. 

large shoulders of the porter, the massive arms of the 
baker, are without vigour and energy, and weak in 
consequence of their development, or hypertrophy. 
How can you attribute to active aneurism, or hyper- 
trophy, symptoms of obstruction to the circulation? 
Have you forgotten that in all cases of pure and sim- 
ple hypertrophy, the patients have a full, vigorous 
and vibrating pulse; that the movements of the heart 
are regular and full of force; that the face is bright 
red; that they are subject to all the active hemor- 
rhagies? But will you say, we have frequently met 
with the symptoms of obstruction to the circulation 
above mentioned, in cases of hypertrophy? Undoubt- 
edly. But could you draw this strange conclusion, 
that hypertrophy of the heart is a cause of embar- 
rassment to the circulation? If you had reflected upon 
this subject more attentively, you would have ob- 
served that, in the cases of which you speak, the hy- 
pertrophy is complicated with another lesion, for ex- 
ample, contraction of the orifices, or other affections 
capable of opposing an obstacle, either mechanical or 
vital, to the course of the blood. You would cer- 
tainly have confounded the symptoms of one disease 
with those of another, or rather you would have 
taken the effect for the cause; because in the cases 
where there exists an obstacle to the circulation, the 
hypertrophy, the aneurism which you call active, is 
a consequence or accident of that obstacle. So that 
if you refer henceforth to active aneurism all the 
symptoms, instead of referring them to the obstacle 
in question, you will fall into an egregious error; 
since you take one of the accidents of the disease for 
the disease itself, or the point of departure of all the 



DISEASES OF THE HEART. 357 

other symptoms. We cannot insist too strongly on 
this subject: because this error of authors, deeply im- 
pressed on many minds, is also that of the physicians 
of the present day, and of some of the most estimable 
among them. Let us endeavour then to distinguish 
these two things; namely, hypertrophy, and a me- 
chanical or vital obstacle to the circulation. The 
first, cannot of itself give rise to the symptoms which 
announce a great impediment to the course of the 
blood. * This opinion is not purely theoretical; it is 
the expression of facts, and of accurate observation. 
Call to mind, in fact, the patients of the seventy-fifth, 
seventy-sixth, and seventy-seventh cases, and many 
others; examine with attention the cases of pure and 
simple hypertrophy contained in other works, and 
you will be convinced that in these cases, we do not 
meet with the fades propria, the infiltration, and the 
other symptoms of an obstacle to the circulation; you 
will see, on the contrary, that the sanguiferous sys- 
tem enjoys a greater activity of movement; and will 
hence explain to you how it happens that many pa- 
tients are carried off, not by hypertrophy itself, but 
by either hemorrhagic or inflammatory affections of 
the brain, lungs, &c, affections which, as has been de- 
monstrated above, are connected with hypertrophy 
of the heart, by the most intimate relation. 

* The only case in which hypertrophy may become an obstacle to the cir- 
culation, is that in which it affects the part from without inward, and, follow- 
ing*, as we may say, a centripetal course, invades a portion of the cavity, and 
contracts it to such a point that the passage of the blood through it is con- 
siderably interrupted. This case is equivalent to a contraction of some one 
of the orifices of the heart; but is not by any means so common. 



358 DISEASES OF THE HEART. 



C. Distinctive Symptoms of Hypertrophy of each of 
the Cavities of the Heart. 

1st. Symptoms of hypertrophy of the left ventricle. 
— The pulsations of the heart, the characters of which 
have been above analyzed, are particularly felt in the 
region of the cartilages of the fifth and sixth ribs : this 
is the situation in which they occur with the great- 
est intensity; they become weaker in the remaining 
portion of the left side, but are, nevertheless, more 
marked there than in the right side. Lastly, to these 
symptoms we must also add those furnished by the 
examination of the general circulation. But, as we 
have already mentioned elsewhere, individuals affect- 
ed with hypertrophy of the left ventricle, have the 
face coloured red or vermilion; the eyes brilliant; 
the pulse strong, hard, vibrating and full, at least 
when the cavity is not contracted; they are subject 
to active hemorrhagies, especially to bleedings from 
the nose, to vertigo and other symptoms of cerebral 
congestion which not unfrequently destroys the pa- 
tient. 

2d. Symptoms of hypertrophy of the right ventri- 
cle. — Contractions, the characters above described, 
instead of being felt in the interval between the 
fourth and fifth ribs, are much more pronounced un- 
der the inferior part of the sternum, and, in general, 
more marked in the right than in the left side of the 
chest. 

We shall cease to be astonished that the pulsations of 
each ventricle may be specially felt in a determinate 
place, corresponding to the situation of each of them, 






DISEASES OF THE HEART. 35$ 

if we will but reflect that some patients can distin- 
guish very well of themselves on which side the 
heart beats the strongest. It was thus that the pa- 
tient in the ninety-first case, for example, had ob- 
served, and assured us that the palpitations with 
which she was troubled, were much more violent 
in the right than the left side; a symptom which 
corresponds with the disease of the right auricle. 
Another symptom of hypertrophy of the right ven- 
tricle is the expectoration, of a pure and vermi- 
lion coloured blood at intervals more or less frequent. 
This active hemoptysis is to hypertrophy of the right 
ventricle what apoplexy, properly speaking, is to that 
of the left ventricle. We have said, after Lancisi, 
that the pulsation or the fluctuation of the jugular 
veins, is a symptom of some affection of the right ven- 
tricle. This remark is not without foundation; but 
the jugular or venous pulse is never observed, ex- 
cepting in the cases where the dilatation accompa- 
nies the hypertrophy, and when the auriculo-ventri- 
cular orifice, being much enlarged, can no longer be 
completely closed by its valve: hence the afflux of 
blood in the large veins during the contraction of the 
right ventricle. We shall renew the consideration 
of this phenomenon hereafter, when speaking of the 
dilatation of the heart. 

Having given the symptoms of each of the forms 
of hypertrophy, whether it affect the left ventricle, 
or whether it affect the right, it is evident that we* 
are ignorant of those which characterize the various 
combinations of these several forms of hypertrophy 
from each other, and those which indicate that the 



360 DISEASES OF THE HEART. 

disease is located in both ventricles at once. An in- 
dividual, for example, may be simultaneously affected 
with aneurismal hypertrophy of the right ventricle, 
and with simple hypertrophy, or even a certain de- 
gree of contraction of the left: in the first case we 
shall meet with strong, clear and sonorous pulsations, 
to be heard more particularly in the inferior part of 
the sternum; and in the second, contractions equally 
powerful, but dull and concentrated; which we shall 
hear, in the interval, between the cartilages of the 
fifth and sixth ribs. 

As to the hypertrophy of the auricles, we shall be 
able to recognise it by the more or less stifled sound 
which accompanies their contractions. As this hy- 
pertrophy is, farthermore, almost constantly conse- 
cutive to a lesion of the valves, or an obstacle to the 
circulation, it will be sufficient, in order to ascertain 
it, to recognise the existence of such an obstacle. 
This hypertrophy, however, is not very important 
to ascertain, and is much less dangerous of itself, than 
from the cause which produces it. 

In finishing what we have to say respecting the 
symptoms of hypertrophy of the heart, it is well to 
add that auscultation mediate is, in general, prefera- 
ble to auscultation immediate; and that the signs fur- 
nished by this invaluable mode of exploration, how- 
ever precise or faithful they may have been, would 
prove the source of erroneous diagnosis, if they had 
been collected carelessly or with too great preci- 
pitation, and if we did not take into account all 
the complications with which hypertrophy may be 
accompanied; such as congestion of blood, soften- 



DISEASES OF THE HEART,, 361 

ing and hardening of the texture of the heart, con- 
traction of its orifices, and diseases of the aorta, 
lungs, &e. 



SECTION VI. 

PROGRESS AND TERMINATION 01 HYPER- 
TROPHY OF THE HEART 

It is impossible to establish any precise law rela- 
tive to the progress of this disease. The reason of 
this, as may be easily conceived, is because the hy- 
pertrophy is very rarely primitive, but more com- 
monly consecutive, and, consequently, subordinate 
in its course to the progress even of the causes and 
various lesions which might have produced it; sub- 
jects which have been already discussed, and which 
the reader ought to have present in his memory. We 
shall only say here that the progress of hypertrophy 
of the heart is, in general, slow, tardy, and chronic; 
but that in some cases, however, it affects a more ra- 
pid, active, and, as it were, acute form. 

We have already said that hypertrophy of itself is 
rarely dangerous, and perhaps never mortal; but we 
have seen that it exercises on many organs, and es- 
pecially on the brain and lungs, such an influence as 
to lead even to a fatal result, numerous examples of 
which have been already related. 

Farthermore, this termination, as well as the pro- 
gress of the nutritive irritation, are singularly modi- 
fied according to an affinity of individual circum- 

46 



362 DISEASES OF THE HEART. 

stances, and according to the diseases which accom- 
pany or are, in some measure, connected with it. 
We cannot, therefore, too frequently repeat that it is 
on these last, particularly, that the physician should 
fix the whole of his attention, and that frequently the 
hypertrophy does not merit on its own account any 
thing more than a secondary consideration. 



SECTION VII. 

TREATMENT OF HYPERTROPHY OF THE 
HEART 

If our ideas of this disease are perfectly understood, 
it will be readily foreseen what the treatment should 
be. It is beyond all doubt, in the first place, that in 
cases, so frequently occurring, in which hypertro- 
phy is purely consecutive, our therapeutic measures 
should be directed against the disease on which it 
depends. It is no less clear, that we should com- 
mence in all cases by removing the known causes of 
the disease. As to the agents, which we ought to 
employ against the hypertrophy itself, they must, for 
the most part, be sought for amongst the debilitants 
and antiphlogistics. Have we not proved, in fact, 
that the necessary result of the hypertrophy of the 
heart is to communicate a too violent impulse to the 
mass of the blood, to impress too violent shocks on 
the whole arterial system, and to terminate very fre- 
quently in various active hemorrhagies? Consequent- 



DISEASES OF THE HEART. 363 

ly, the sedative method, and blood-letting, naturally 
present themselves as the only true methods proper to 
combat the disease which occupies us : but we have 
considered this mode of treatment sufficiently in detail 
in various parts of this work, and especially when 
speaking of the phlegmasia and aneurism of the aorta, 
so that it will be only necessary to refer the reader 
to it: to renew the exposition of this mode of treat- 
ment would be a loss of time entirely wasted in wea- 
risome repetitions: we shall only add that physicians 
ought, perhaps, to recur with more hardihood than 
they have been accustomed to do, to the method of 
Valsalva and of Albertini. It has been satisfactorily 
ascertained, from numerous cases, that this has cured 
a number of hypertrophies of the heart of the first 
and even of the second degree. There are, how- 
ever, few patients endowed with a sufficient quan- 
tity of patience, and confidence sufficiently firm to 
resign themselves to all the severity of the method 
of treatment which we recommend. We are so 
much the more led to approve this method, as a va- 
luable fact, recorded by Professor Laennec, seems 
to demonstrate that, by its employment, the heart 
diminishes considerably in volume, becomes, in some 
manner atrophous, as happens with the external 
muscles which have been long condemned to inac- 
tion.* 

After having studied hypertrophy of the heart, 
we should afterwards occupy ourselves with atro- 
phy, or hypertrophy of that organ: this would be fol- 
lowing the most natural order, and the one which 

* De PAuscult. Med., torn. ii. page 293, et Suivantes. 



364 DISEASES OF THE HEART. 

seems to present itself in the first instance. How- 
ever, as dilatation of the heart has heen a matter of 
some discussion in the preceding chapter, we have 
thought it would be proper to examine this new spe- 
cies of disease before we begin with the history of 
thinness and atrophy of the walls of the heart, 



DISEASES OF THE HEART. 365 



CHAPTER II. 



OF DILATATION OR ANEURISM OF THE HEART. 



PRELIMINARY CONSIDERATIONS. 

Lancisi first designated dilatation of the heart by 
the name of aneurism, or rather consecrated an ex- 
pression which had been already employed by Bail- 
lou. Morgagni employed the term dilatation and 
aneurism indifferently : Corvisart has also given the 
name of aneurism to the dilatations of the heart, in 
acknowledging, w T ith Morgagni, that this denomina- 
tion was far from being perfectly exact, if we wished 
to denote by it a disease of the heart, perfectly simi- 
lar to the arterial dilatation, which surgeons describe 
under the name of aneurism. 

Corvisart continued, however, to distinguish the 
dilatations of the heart by the name of aneurism, 
and, what had not been done before, he established 
two distinct species; one of which he designated by 
the term active aneurism, and the other by the term 
passive aneurism. In the first species, the parietes of 
the heart are dilated, and at the same time thickened^ 
the force of the organ being augmented; in the se- 
cond, the cavities of the heart are evidently dilated, 



366 DISEASES OF THE HEART. 

but they are also wasted, and the action of the organ 
is weakened. This double disposition of the parietes 
of the heart has been long since observed and demon- 
strated: Morgagni, especially, has cited numerous ex- 
amples; but it is surprising that another form of dilata- 
tion has escaped the sagacity of this illustrious anato- 
mist, as it had been concealed from the investigation 
of his predecessors, and as it eluded the researches 
of his most celebrated successors. The form we re- 
fer to is that in which the parietes of the heart are 
dilated without having suffered any change in their 
natural thickness, and respecting which we have col- 
lected a great number of observations. 

But our own researches on the dilatations of the 
heart have given rise to some doubts respecting the 
doctrine of the celebrated professor of chemical me- 
dicine, and have changed the ideas we had derived 
from the learned lectures of that illustrious physi- 
cian, who was one of our first masters. We recollect 
especially that in treating of aneurism with thicken- 
ing, we have not sufficiently regarded the nature of 
the latter, nor the diseases with which aneurism has 
been complicated; and that there has, in truth, re- 
sulted from this kind of negligence a discordance be- 
tween observation and the general results which 
have been deduced from them; a contradiction, if we 
may be permitted to say so, between facts and prin- 
ciples. 

Lastly, we ought to recall here what we have said 
in the preceding section; namely, that there has been 
some error in not distinguishing aneurism and dilata- 
tion of the heart from hypertrophy; and, that active 
or passive aneurism is not a simple but a compound 



DISEASES OF THE HEART. 367 

disease, formed, in the first instance, of hypertro- 
phy and dilatation, and, in the second, of dilatation 
and wasting of the parietes. 

These general remarks being premised, we shall 
proceed presently to give the history of the aneu- 
rism of the heart; an expression which, to us, is abso- 
lutely synonymous with dilatation, and to which we, 
consequently, attach no other idea than that which 
its etymology denotes. 



ARTICLE I. 

CASES OF DILATATION, OR ANEURISM OF THE 
HEART. 

In the preceding section we have given a great 
number of cases of the two forms of dilatation of the 
heart; namely, that with a natural state of the pari- 
etes, and that with thickening of those parietes. We 
know, indeed, that these two kinds of disease con- 
stitute the hypertrophy which we have called aneu- 
rismal s* we shall content ourselves then in reporting 
here an example of the third form of dilatation which 
we have observed, or that with wasting of the pari- 

* The cases 78 and 79, to be found in the preceding* section, and a great 
number of those related in the first part of this work, appertain to dilatation 
with thickening* of the parietes; a compound disease, which might, with 
equal propriety, be called aneurismal hypertrophy, or hypertrophic aneu- 
rism. 

Case 80, and those marked 86 and 87, are examples of dilatation of the 
ventricles of the heart, without any change in the thickness of their parietes. 
We would, if space permitted, offer many other similar cases. 



368 DISEASES OF THE HEART, 

etes. We should choose among the facts of this kind 
which we have collected, a case in which this kind of 
dilatation was ascertained by auscultation, and an- 
nounced a long time before we were permitted to con- 
firm its existence by an examination of the body. 

Case XCI. 

Dilatation of the Ventricles with wasti?ig of their Parietes; In* 
testinal Ulcers; Pulmonary Tubercles, fyc. 

Jean Nicholas Mougenot, thirty-one years of age, 
tailor's apprentice, ex-grenadier of the guard, of a 
lymphatic constitution; long and narrow chest, skin 
white and delicate, hair red, of a mild disposition, 
entered the hospital Cochin on the 30th of July, 1822. 
He said that he had suffered several severe attacks of 
catarrhal affection, accompanied with spitting of 
blood; he had emaciated very much, especially with- 
in six months, and presented, in other respects, the 
following phenomena: — cough, thick, copious, mu- 
cous greenish sputa, not streaked with blood, with 
which he had been troubled for six weeks; loss of 
breath, and dyspnoea on the least exercise; rattling 
with gurgles is heard, and very strong pectoriloquy 
in almost the whole of the right side of the chest: in 
several other parts of the chest the rattle resembles 
a slight clapping; the impulse of the pulsations of the 
heart are very weak; the pulsations of the ventricles 
are clear, somewhat analogous to the effect produced 
by tapping lightly on the head of a drum, differ- 
ing but little from those of the auricles, excepting 
that they are a little more prolonged; they are heard 
even at the posterior part of the chest. Tongue dry. 



DISEASES OF THE HEART. 369 

and red; thirst, loss of appetite, nausea, and some- 
times vomiting after the fits of cough; diarrhoea with- 
out colic,, heat of the skin, night sweat, pulse small, 
frequent and feeble; hectic fever, simulating an in- 
termittent quotidian;, insomnia. (Gum r edul., tinct. 
quart.) 

12th of August, a pleuritic stitch occurs in the re- 
gion of the right heart, pectoriloquy in both sides of 
the chest, gurgling or panting respiration; the pul- 
sations of the heart are weak, without impulse, and 
always clear; prostration^ paleness and discoloration 
of the skin, threatening suffocation. These symptoms 
continued until the 17th: — faint turns, frequent dim- 
ness of sight, agony,, tranquil death on the night of 
the 17th. 

Inspection of the Body eighteen Hours after Death. 

1st. Chest. — In the right side of this cavity were 
false membranes of variable consistence: at the base 
and in the middle they are soft, pulpy, and injected; 
they are considerably thickened towards the summit, 
where their presence seems destined to prevent the 
effusion of the tubercular matter in the sac of the 
pleura. In fact, the whole of the right lung forms a 
large mass, of the consistence of liver, divided in its 
superior portion into a great many excavations; cut 
in several different parts, its substance presents a gra- 
nulated substance, not in the least spongy; at the sur- 
face of the incisions, are seen the orifices of a great 
many of the bronchial tubes. This substance is of a 
grayish black, it is traversed by semi-transparent la- 
minae somewhat lardaceous, which appertain to the 
thickened pleura covering the pulmonary fissures, 

47 . 



370 DISEASES OF THE HEART. 

The left lung less voluminous than the preceding, is 
crepitant at its anterior edge, whilst its posterior is 
swelled with serum, and contains granular tubercles; 
we find here and there, in this lung, many tubercu- 
lar deposites of moderate extent; the bronchial gang- 
lions, voluminous and black are transformed, in the 
centre, into a white pultaceous substance; the bron- 
chise are red, covered with mucus, and grumous mat- 
ter proceeding from the pulmonary excavations; the 
left side of the chest contains a moderate quantity of 
lemon coloured serum; but few adhesionsare observed. 
The heart is large for a patient with ph thy sis: its pa- 
rietes are soft, flabby and depressed; the right ven- 
tricle is a little larger than in the natural state; the 
left ventricle is a little larger than the right. This 
aneurismal dilatation takes place at the expense of 
the thickness of the parietes, which hardly exceeds 
that of the parietes of the right ventricle; the auri- 
cles do not present any considerable change either in 
their extent or their thickness; their valves present 
a violet red colour. The pericardium contains a lit- 
tle serum. 

2nd. Abdomen. — The liver is very large and less 
compact than the right lung of the subject, a little 
softened and very easily torn; the stomach is very 
large, and presents on its internal surface a violet 
and, as it were, an almost aneurismal red colour; the 
external layer of the mucous membrane is softened, 
and easily torn, leaving underneath reticulated 
patches of injected vessels; the jejunum and duode- 
num offer a red colour, and are injected similarly to 
that of the stomach: this redness is continuous, whilst 
in the ilium it is interrupted by spaces more or less 



DISEASES OF THE HEART. 371 

considerable, where it entirely fails; the intestinal 
parietes are soft and infiltrated; the large intestine, 
very long, contains semi-liquid substances, and is ge- 
nerally injected: very numerous ulcerations are met 
with, especially in the ccecum, where they are much 
distended and elongated. 

3d. The cranium has not been opened. 

The nature of the ventricular pulsations, their ex- 
tent, the clear sound, and scarcely perceptible im- 
pulse, were sufficient to announce, from the first, 
the existence of dilatation, with wasting of the ven- 
tricles; and the inspection of the body has perfectly 
confirmed such a diagnostic* These signs deserve 
to be classed among those which characterize the 
passive aneurism of Corvisart in the most positive 
manner. 



ARTICLE II. 

GENERAL HISTORY OF DILATATION AND ANEURISM 
OF THE HEART. 



SECTION L 

ANATOMICAL CHARACTERS, AND VARIOUS FORMS OF DI- 
LATATION OF THE HEART. 

The only anatomical character which constitutes^ 
if we may be allowed the expression, the disease 
which we are considering, is the enlargement of one 



372 DISEASES OF THE HEART. 

or more of the cavities of the heart. It is very true, 
that, at the same time that the parietes are dilated, 
we find thern frequently either thickened or wasted; 
but this thickening, or wasting, is not the insepara- 
ble condition of aneurism; they do not constitute it; 
analysis would lead us to distinguish and view them 
as particular diseases which complicate the other af- 
fections of the heart. It is according to the states in 
which the parietes may be found that we shall admit 
three distinct forms of dilatation of the heart, as we 
have admitted three forms of hypertrophy, founded 
on the condition of the cavities of that organ. 

The first form of dilatation is that in which the pa- 
rietes are at the same time dilated and thickened: 
this is the most frequent, and constitutes the active 
aneurism of Corvisart, or our second form of hyper- 
trophy. (See the preceding chapter.) The second 
form is that in which the parietes are dilated as well 
as thinned; it is less frequent than the preceding; and 
constitutes the passive aneurism of Corvisart. Lastly, 
the third form is distinguished from the preceding in 
this, that the dilated parietes preserve their natural 
thickness. This form, which we were the first to de- 
scribe, is also almost as frequent as the first, and might 
have been designated by the name of simple dilata- 
tion.* 

To these three forms of dilatation we might add a 
fourth, under the name of mixed dilatation, because 
it is a compound of the others. In this species, the 

* It is yet more surprising, as this form of dilatation, until the present 
time, has not been either the subject of a division, or of any particular deno- 
mination, although we find numerous examples of it in various collections of 
cases, and especially in the works of MorgagnL 



DISEASES OF THE HEART, 373 

parietes of the dilated cavity are thickened in some 
paints of their extent, thinned in others, and in the 
rest preserve their natural thickness; M. Portal ap- 
pears to have observed it. 

The dilatation of the cavities of the heart presents 
various degrees of extent: when it is very considera- 
ble, especially if it be complicated with hypertrophy, 
the heart acquires an immense size, changes its form, 
becomes rounded and enlarged, and resembles, as we 
have already said, a kind of pouch. 

Some authors have mentioned, as characteristic of 
dilatation of the heart, the softening and alteration of 
colour of its muscular substance; but we shall say of 
these characters what we have said of the thinness 
and thickness of the parietes, that they constitute 
true complications which may exist without dilata- 
tion, as this may exist itself without meeting with the 
others. We shall presently see why, in the great di- 
latations of the heart, we find its veins distended, its 
texture swelled with blood, and of a more or less deep 
red tint 

SECTION II. 

FORMATION AND CAUSES OF DILATATION OF THE HEART. 

A phenomenon which attentive observation does 
not permit us to overlook is, that all the hollow or- 
gans dilate more or less considerably, when, in con- 
sequence of any obstacle, the fluids or solids which 
they are destined to contain accumulate in their ca- 
vity, and react on their parietes. The organ allows 
of distention so much the more readily, as its parietes 
are endowed with less energy, or the causes of dila- 



374 DISEASES OF THE HEART. 

tation are more active. If these causes are not per- 
manent, the organ whose resistance has been mo- 
mentarily overcome, soon resumes its former state; 
so that if the causes be, on the contrary, continuous, 
or act too frequently, the dilatation of the organ 
becomes comitant, no longer disappears, and con- 
stitutes a true pathological state. These reflections, 
which have been furnished us by very numerous facts, 
and which have served to explain the dilatations of 
the aorta, apply most admirably to those of the heart. 
Notwithstanding the structure of the heart and the 
aorta presents the most remarkable differences, the 
mechanism of their dilatation is essentially the same; 
and as we have seen that the aneurism of the aorta 
recognises for its immediate cause the accumulation 
of blood in its cavity, and the lateral reaction of this 
liquid, so the aneurism of the heart takes place by 
the action of the blood which distends its cavities, 
and tends to enlarge its parietes, by removing them 
from the axis or centre of these same cavities. If 
the obstacle which determines the distention of the 
cavities of the heart disappear at the end of a cer- 
tain time, and is not again renewed, the distended 
parietes react and return to their first condition. 
This is what has taken place, for example, in the cases 
in which an acute disease of the lungs has determined 
a stasis or accumulation of blood in the cavities of the 
heart situated behind them; but if the obstacle per- 
sist indefinitely, or be repeated without cessation, as 
in those professions which require exertions to be 
constantly renewed, or in the contractions of the ori- 
fices of the heart, the reaction of this hollow muscle 
is overcome by the redoubled efforts of the blood, the 



DISEASES OF THE HEART. 375 

dilating force of the blood exceeds the elastic and 
contractile force of the heart,* which becomes the 
seat of a morbid dilatation more or less considerable. 
It is impossible to fix on a space of time during which 
the heart can thus wrestle effectually against the 
power which tends to develop its parietes; but it is 
certain that it will resist as much longer as its mus- 
cular texture is more robust. For this reason, the 
auricles dilate with more facility than the ventricles, 
and of these the left dilates much less frequently than 
the right; whilst, as we have seen, hypertrophy at- 
tacks it much more frequently than the other. The 
theory which we have exhibited requires that that 
dilatation or aneurism of the heart be classed among 
the diseases purely mechanical. It is, also, the place 
which ought to be assigned to them in the present 
day, if, as recent experiments seem to demonstrate, 
the heart be not susceptible of an active dilatation, 
its diastole being a movement perfectly analogous to 
that by which an ordinary muscle relaxes and returns 
to its habitual state, after having been contracted. If 
all these data be exact, the expression active aneu- 
rism is composed of two w 7 ords, which, in some mea- 
sure, contradict each other; since, of itself, aneurism 
does not possess any character of activity 7 a new mo- 
tive for not employing this word, excepting as exact- 
ly synonymous with dilatation. 

We have established the following principle: that, 
in dilatations of the heart some are temporary ', while 
others are permanent. These last, alone, constitute 

* The heart may be ruptured in the expulsive efforts to which it is ex- 
posed, in the same manner as the uterus is torn, during" the too violent ex- 
pulsive contractions: such, at least, is the opinion of Burns. 



376 DISEASES OF THE HEART. 

a truly pathological state; the others would be more 
appropriately designated by the term distention. In 
confounding them with each other, Pasta has commit- 
ted a serious error. It is very true, that the simple 
distention of the cavities of the heart might pass into 
the state of true dilatation, and that it is not necessa- 
ry, for that purpose, that there should be a prolonga- 
tion or repetition of the action of the productive 
cause; but this reason is not sufficient for confound- 
ing together two things which present many distinc- 
tive characters. 

Constant, permanent, morbid dilatation will be dis- 
tinguished from that which is only temporary by this 
circumstance: that the first does not disappear after the 
evacuation of the blood that filled the cavities of the 
heart; this, at least, partially takes place in the other 
species of dilatation, which is ordinarily the effect of 
a prolonged agony, during which the course of the 
blood has been considerably embarrassed. 

As to the causes immediately determining aneu- 
rism of the heart, they are essentially the same as 
those which produce aneurism of the aorta and hy- 
pertrophy. We shall therefore only notice the prin- 
cipal of them; such as contractions of the orifices of 
the heart, and all those diseases which impede the 
course of the blood, whether in the lungs, or in the 
system of the great circulation, &c* 

* As dilatation of the heart is produced by the presence of a too large 
quantity of blood in the cavities of that organ, we may conceive why the tex- 
ture of a dilated heart is of a more or less deep red. This colour dependi 
on the venous distention of the heart 



DISEASES OF THE HEART. 377 



SECTION III. 

OF THE SYMPTOMS AND DIAGNOSIS OF DILATATION OR 
ANEURISM OF THE HEART. 

In the preceding chapter, we have already said 
that the dilatation of the heart had the effect to ren- 
der the sounds which accompany its contractions 
more clear and resonant. We have already described 
the symptoms which announce dilatation with hyper- 
trophy, and dilatation with a natural state of the pa- 
rietes; nothing more remains for us but to limit those 
which accompany dilatation with thinness of the pa- 
rietes. We shall recognise this form of aneurism, 
which we have supposed at first to affect the ventri- 
cles, by a clear loud sound, which is heard during 
their contractions, and which, when the thinness is 
considerable, resembles almost exactly that of the au- 
ricles; at the same time the impulse which accompa- 
nies these contractions is very feeble, or even entire- 
ly inappreciable. It is by means of these signs that 
we have been able to form a diagnosis of passive 
aneurism, the dilatation with wasting of the parietes 
of the ventricles with which the patient in our nine- 
ty-second case was affected.* Dilatation of the au- 
ricles, when consecutive to the contraction of the ori- 
fices of the heart, may be ascertained by the same 
symptoms as those of the latter lesion. As to the di- 
lation produced by other causes, the cylinder has not 
as yet furnished any signs which would announce it 

* It is necessary to repeat, that we shall be able to distinguish the dilata- 
tion of either of the ventricles by the situation in which the pulsations indi- 
cated may be heard. 

48 



378 DISEASES OF THE HEART. 

in an indubitable manner. This diagnosis is, besides, 
of very little importance, as has been already ex- 
plained. 

Authors have discussed at length what are called 
the general symptoms of dilatation, or aneurism of the 
heart, and they have allowed themselves to be led into 
great errors, by considering the dilatation as a primi- 
tive disease, instead of regarding it as the consequence 
of some other lesion, which had been the source of 
the symptoms that had been attributed to the dila- 
tation itself. We have proved, a little farther back, 
that this disease necessarily supposes an obstacle to the 
course of the blood; but this obstacle, at the same time 
that it gives rise to an aneurism of the heart, produces 
other very striking phenomena, such as distention of 
the vessels, serous infiltration, passive hemorrhagies, 
&c. These phenomena have been taken for the ef- 
fect of the dilatation of the heart, whilst the latter 
has not, strictly, any other relation with them than 
being the result of the same cause; that is to say, an 
embarrassment of the circulation. 

Before the method of auscultation was known, 
symptoms were sought for which would enable us 
to distinguish aneurism of the right cavities from 
that of the left. Lancisi has given, as a symptom of 
aneurism of the right cavities, a fluctuation of the 
jugular veins. Corvisart thinks that this diagnostic 
is variable, very difficult, and very uncertain : he as- 
sures us, nevertheless, that in the case of dilatation 
of the right cavities, the suffocation is greater, the 
serous diathesis is more marked, the haemoptysis more 
frequent, and the livid aspect of the face deeper. 

From all we have heretofore established, it is in- 



DISEASES OF THE HEART. 379 

dubitable that the phenomena pointed out by Lancisi 
and Corvisart announce, in fact, a dilatation of the 
right cavities, or at least a difficulty in their circu- 
lation; but it frequently happens that the real cause 
of the dilatation is to be found somewhere else than 
in the right cavities. Thus, for example, this cause 
frequently consists in a contraction of the aortic ori- 
fice, or of the left auriculo-ventricular orifice. Now, 
in these cases, the constriction is the principal and 
essential disease, and the aneurism of the right cavi- 
ties is a secondary and in some measure a sympto- 
matic lesion, as well as the obstruction, and the ve- 
nous pulse (symptom of Lancisi,*) the infiltrations, 
and the passive hemorrhagies. It is of great impor- 
tance that we have a perfect knowledge of all these 
truths, that we may not mistake, as has too frequent- 
ly been done, a mere symptom, or pure accident, for 
the principal, or even the whole disease. 

SECTION IV. 

OF THE EFFECTS OF DILATATION OR ANEURISM OF THE 

HEART. 

We have already shown above, that the dilatation 
of the heart is the mechanical result of a cause which 

* It will, however, be proper to distinguish two phenomena which are 
ordinarily confounded under the name of venous pulse; namely, the move- 
ment of expansion, and distention, which we observe in the veins when the 
pulmonary circulation is impeded, and the kind of pulsation which we re- 
mark in the same parts, when, during' the contraction of the right ventricle, 
a certain quantity of blood reverts towards the auricle, and the venous sys- 
tem. The first movement is isochronous with that of expiration. The second 
corresponds to the pulse and to the ventricular contractions: both of them 
are sometimes observed in the same subject. 



380 DISEASES OF THE HEART. 

determines an engorgement of the cavities of that or- 
gan ; and, that it is to the action of that cause, rather 
than to the dilatation itself, that we must refer the 
various symptoms which authors have attributed to 
the latter. Granting the dilatation to have taken 
place, we must next inquire, what may be its influ- 
ence on the system of circulation, and thence on the 
whole economy. Now, it is very evident, that, con- 
sidered in the abstract, the dilatation of the heart has 
the effect to weaken the contractile power of the mus- 
cular substance of that organ, in consequence of the 
distention to which it is subjected. The muscular 
fibres lose in strength what they acquire in extent. 
If, therefore, we could have a correct idea of dilata- 
tion, wholly distinct from the cause which determines 
it, we should assign for the symptoms, weakness and 
softness of the pulse, dropsy, and passive hemor- 
rhage; in one word, all those phenomena which we 
know to be the result of an obstacle to the circula- 
tion ; but, as the cause of the dilatation is itself pro- 
per to produce all these phenomena, it is very diffi- 
cult to distinguish from the dilatation and the cause, 
the proper influence of the latter in the develop- 
ment of similar effects. It will undoubtedly be ob- 
jected to us here, that, in active aneurism, we observe 
symptoms directly opposite to those we have related ; 
but this objection cannot be addressed to us, except- 
ing by those who have not reflected sufficiently on 
the ideas which we have proposed in several parts of 
this work. In fact, if you notice the symptoms of 
active circulation, in individuals affected with active 
aneurism, certainly it is not to the dilatation that 
this activity pertains, but in reality to the hypertro- 



DISEASES OF THE HEART. 381 

phy with which it is complicated. In this case, the 
heart receiving more energy, by means of hypertro- 
phy, than it loses by the dilatation with which it 
is affected, the symptoms of hypertrophy predomi- 
nate over those of dilatation. The contrary takes 
place, when the dilatation is complicated with 
wasting of the parietes, and is effected at the expense 
of their thickness. Lastly, we may conceive a third 
case, in which the heart gains, by virtue of its hy- 
pertrophy, precisely as much as it loses, in conse- 
quence of its dilatation, from which results a kind of 
compensation, or equilibrium, which maintains its 
functions in their normal state ; but, as this idea ap- 
pears to us much more fanciful than real, we shall 
barely notice it. 

SECTION V. 

TREATMENT OF DILATATION AND ANEURISM OF THE 
HEART. 

We have spoken, in the preceding section, of the 
treatment which is proper for aneurism complicated 
with hypertrophy; we shall only occupy ourselves 
here, with that which we ought to employ for simple 
dilatation, and dilatation with wasting or hypertrophy 
of the parietes ; but, if it be true, that dilatation of 
the heart is uniformly consecutive, it is evident, that 
the treatment ought essentially to consist in combating 
the cause, or the disease on which it depends. If we 
succeed in removing the latter, the dilatation will be 
gradually dissipated of itself; because the cause being 
destroyed, the effect ought to disappear, at least when 
the dilatation has not advanced to such a degree, as 
to extinguish entirely the retractility of the muscular 



382 DISEASES OF THE HEART. 

fibres, and to deprive them of all their elasticity, a 
case which would be beyond all the resources of art; 
of itself, the dilatation of the heart is the source of 
scarcely any indication. Is it the result of a contrac- 
tion of the orifices? then this latter disease should be 
the object of the treatment. Is the cause to be re- 
ferred to an obstacle to the pulmonary circulation, 
such as that produced by pleurisy, or pneumonia, 
tubercles, or hydrothorax? pulmonary diseases evi- 
dently require all the discretion of the physician. Is 
it the effect of too violent exertions, or occupations 
which obstruct the free course of the blood, of pas- 
sions too easily excited? the indication will always 
present itself. These various considerations are suf- 
ficient to excuse the limited extent of this para- 
graph.* 

* In terminating the history of dilatation of the heart, we ought to speak 
of that which occupies only one portion of one of the cavities of that organ; 
we mean partial dilatation. This kind of dilatation is analagous to the lateral 
aneurism of the arteries. Burserius had nearly discovered it, when he proposed 
to make the same division of the aneurisms of Lhe heart as of those of the ar- 
teries. An example of the partial dilatation of the heart may be found in the 
Miscellanea Naturx Curiosorum: another has been recorded by Corvisart. 
This illustrious physician found in a young negro, who died in a state of 
suffocation — "the superior and lateral part of the left ventricle surmounted 
with a tumour almost as large as the heart itself. The interior of this tumour 
contained several layers of coagula, somewhat dense, perfectly similar to 
those which fill the cavities of the aneurisms of the arteries. The cavity of 
this tumour communicated with that of the ventricle by an opening which 
was rather small, and the circumference of which was smooth and polished."* 
We have never observed any tiling similar to this interesting fact. But we 
have not unfrequently found, as we have already said, one of the cavities of 
the heart dilated in one portion of its extent, whilst it presented elsewhere 
its natural state, or was even contracted. It is not uncommon, for example, 
to find that portion of the right ventricle which is nearest the pulmonary ar- 
tery considerably dilated, whilst the rest of that ventricle retains its ordinary 
size. 

* Essai sur les Maladies du Wei?h P* 263. 



DISEASES OF THE HEART. 383 



CHAPTER III. 

ATROPHY OF THE HEART. 

Atrophy of the heart has been observed by a great 
many authors; Senac has appropriated an article to 
it in his great work. It is to this disease that the 
passage from the Dictionary of Medical Sciences re- 
fers, which we have quoted verbatim in the first 
chapter of this section. Testa, Burns, Kreisig, and 
M. Laennec, have presented reflections, more or less 
extensive, on the same subject. Burns cites four 
cases of atrophy of the heart; in one of these cases 
the heart of an adult did not exceed in volume that 
of the new-born child; in another, the heart of a girl 
of twenty- six years of age, was as small as that of a 
child six years old. In the subject of our 66th case, 
a young man of strong constitution, and about thirty 
years of age, the heart did not exceed the size of that 
of a very young child. We have observed a pretty 
large number of other examples of atrophy of the 
heart, which would take up too much time to relate. 
Atrophy of the heart more generally occurs, in indi- 
viduals worn out by lingering disease, inducing in its 
progress complete marasmus ; such as, for example, 
we observe in those affected with phthysis, cancer, 
&c. We have seen a heart very little developed in 
an old woman; who, after having manifested evident 



384 DISEASES OF THE HEART, 

symptoms of hypertrophy of that organ, which was 
combated by bleeding, died of chronic diarrhea. It 
seems, in these cases, that the heart participates in 
the general emaciation, and that it at the same time 
reacts upon itself, to accommodate or mould itself to 
the small quantity of blood which circulates through 
its cavities ; in other cases, the atrophy of the heart 
appears to be the result of a compression exercised 
upon itself, for a longer or shorter period. In the 
patient in our 66th case, the atrophy was evidently 
produced by the pressure which the heart had sus- 
tained, from a phlegmasial effusion into the pericar- 
dium ; in this respect, the atrophy of the heart re- 
sembles that with which the lungs are affected, in 
certain cases of effusion from pleurisy. From the 
case of Laennec, which we have cited, the method 
of Valsalva and of Albertini would be sufficient to 
produce atrophy of the heart. In general, when 
the heart is atrophied, its cavities diminish in capa- 
city: it becomes more compacted, as it were, and 
contracts. In consequence of this kind of recep- 
tion, or reaction upon itself, the heart, when really 
atrophous, presents however sometimes a very obvi- 
ous thickening of its walls, which we may very well 
compare to that with which many of the hollow vis- 
cera are affected ; the stomach, and the bladder, for 
example, when they are empty, and contracted 
upon themselves. We shall be grossly deceived, 
if we confound this kind of thickening with hyper- 
trophy, properly speaking. As we have proved, 
that this may exist, without any increased thick- 
ness of the parietes (hypertrophy at the surface,) 
so, we shall presently see, that the thickness of the 



DISEASES OF THE HEART. 385 

parietes may coincide with a true atrophy of that or- 
gan. When the heart is thus emaciated, and shrunk, 
it is, as it were, wrinkled and shrivelled on its surface, 
and, as Laennec observes, pretty nearly resembles a 
shrivelled apple. 

There is another form of atrophy of the heart, 
which ought not to be overlooked. In this, the pa- 
rietes of the heart, and especially of the ventricles, 
instead of being contracted upon themselves, are di- 
lated, and at the same time thickened. This consti- 
tutes the passive aneurism spoken of in the preceding 
chapter. The ventricular parietes are sometimes so 
atrophous, as to resemble membrane, or in fact, the 
parietes of the auricles. It is true, perhaps, that 
this thinness sometimes depends as much on the me- 
chanical distention of the walls, as on the atrophy, 
properly speaking, or diminished nutrition. 

Finally, we may establish a third form of atrophy, 
in which the parietes are thinned, without any change 
in the capacity of the corresponding cavity; a variety 
which corresponds to simple hypertrophy. We shall 
leave the task of deciding this question to future ob- 
servers. 

Atrophy of the heart, with dilatation of the pari- 
etes, appeared rather singular to Senac. "What 
appears most surprising," says he, " is, that the pa- 
rietes of the heart may become thin and wasted, when 
its size has become very large; this, however, has 
happened, as may be proved by a case reported in 
the Ephemerides." I have said, that this fact is sin- 
gular; because, in similar cases, the parietes of the 
heart become ordinarily much thickened.* 

* De la Struct, du Wein, torn. ii. page 394, 
49 



386 DISEASES OF THE HEART. 

Atrophy of the heart being the result of other dis- 
eases, rather than constituting of itself a true disease, 
we have nothing to say of its treatment; it is evidently 
confounded with that of the disease of which it is the 
effect. 

M. Laennec has made a comparison between the 
atrophy and softening of the heart which does not 
appear to us perfectly exact. " I have frequently 
thought," says he, " that softening of the heart is a 
disposition bordering on and precedent of atrophy, 
or hypertrophy. It is, at any rate, like these two 
affections, the product of a certain alteration in the 
nutrition of that organ."* It is precisely, accord- 
ing to us, because the softening of the heart is an 
alteration of the nutrition, that it differs essentially 
from hypertrophy, and atrophy, which are the one 
only an augmentation, and the other only a diminu- 
tion of the nutrition of that organ. We should not 
confound the alteration and perversion of the nutri- 
tion of an organ, with the augmentation and diminu- 
tion of that same nutrition. They are things abso- 
lutely different. 

* AusculU torn. ii. page 295. 



DISEASES OF THE HEART. 387 



CHAPTER IV. 

OF THE INFLAMMATORY IRRITATION OF THE MUSCU- 
LAR SUBSTANCE OF THE HEART, OR CARDITIS AND 
ITS CONSEQUENCES; SUCH AS ABSCESSES, ULCERS, PER- 
FORATIONS, GANGRENE, &c. 



PRELIMINARY CONSIDERATIONS. 

Notwithstanding the writings and observations 
of Galen, of Salius Diversus, Vesalius, Rondelet, 
Forestus, Benivenius, de Riviere, de Kerksing, Mec- 
kel, and some others, general inflammation of the sub- 
stance of the heart is one of those diseases which are 
involved in almost impenetrable obscurity. This is 
not astonishing, if it be true, as M. Laennec asserts, 
that perhaps there is not to be found a single incon- 
testable and well described example of general cardi- 
tis, either acute or chronic. This assertion of a ce- 
lebrated observer, would undoubtedly be true, if it 
had been necessary, in order to admit the existence 
of carditis, to find pus evidently effused into the 
muscular texture of the heart. But, if it be suffi- 
cient to meet with the fleshy substance of that organ 
in a state of softening or hardening, more or less de- 
veloped with augmentation or diminution of its co- 
lour, carditis would no longer be a very rare disease. 



388 DISEASES OF THE HEART. 

and the assertion of M. Laennec would appear at least 
exaggerated. Why, however, should he refuse to re- 
gard the softening and induration of the muscular sub- 
stance of the heart as marks of inflammation of that 
viscus, since the same anatomical characters serve to 
demonstrate the phlegmasia of other organs? Be- 
sides, if you examine attentively what are the pe- 
culiar phenomena which characterize inflammation 
of the external muscles, you will see that the prin- 
cipal are, in fact, the softening and induration. If 
these muscles have been affected with acute phleg- 
masia, you find their tissue brown, chesnut, violet, 
easily torn, or even converted into a kind of sanies, 
or pap, deprived of all cohesion, as happens also to 
other organs, such as the brain, the liver, the lungs, 
the kidneys, the spleen, &c. Now, if you examine 
the muscles at a period more remote from the deve- 
lopment of this phlegmasia, they will present a re- 
markable induration, sometimes cartilaginous, at other 
times even osseous, such as is not uncommonly met 
with after fractures during the formation of the callus. 
These comparisons elucidated, in pathological anato- 
my, will conduct us naturally to class among the cha- 
racters, or, if you will, among the terminations of 
general carditis, the softening and induration of the 
muscular substance of the heart. 

If we have regarded the examples of general car- 
ditis as very rare, it is not so with those of partial or 
circumscribed carditis, characterized by the exis- 
tence of an abscess, or of an ulcer, of greater or less 
depth, of the parietes of the heart. If we were to 
believe some authors, the knowledge of the ulcers of 
the heart may be traced as far back as the time of the 
Egyptians. 



DISEASES OF THE HEART. 389 

However it may be, Bonet has united in his Sepul- 
chetum, a sufficiently large number of cases of ulcers 
and abscesses of the heart. The ulcers of the heart 
have been observed on its internal and external sur- 
face. In the first case, they succeed to a phlegmasia 
of the internal membrane of that organ; in the second, 
they are consecutive to that of the external membrane, 
or to pericarditis. Olaus Borrichius has left us a very 
characteristic example of an ulcer of the external sur- 
face of the heart, as we might judge from the descrip- 
tion which he has given of it, as follows : " Cordis 
exterior caro, prof uncle exesa, in lacinias, et villos 
carneos putrescentes abierat." Peyer and Graetz 
have observed similar cases. The ulcers of the in- 
ternal surface have been noticed and described by 
Bonet, Morgagni, Senac, &c. Whether the ulcer 
proceed from without inwards, or from within out- 
wards, its progress may be followed by a destruction 
of the whole thickness of the parietes affected, with 
a real perforation. We have already occupied our- 
selves with the ulcerations and perforations of the 
heart, in describing the inflammation of the aorta, 
and internal membrane of the heart. We should add 
here some new remarks on the perforations of the 
heart; a disease on which MM. Rostan and Bland 
have each published a memoir, which we would re- 
commend to the reader to consult. We have said, 
elsewhere, (see Diseases of the Aorta,) that it ap- 
peared to us, that the perforations of the heart ought to 
be classed with those which have been described un- 
der the somewhat indefinite expression of spontaneous 
perforations of the stomach, intestines, ulcers, &c. 
Have not the perforations of the heart, preceded by 



390 DISEASES OF THE HEART. 

a deep ulcer, the greatest analogy with those of the 
stomach and intestines ? Does not the antecedent in- 
flammation in both the one and the other exercise a 
very important influence? On the contrary, ought 
not ruptures of the heart, not preceded by ulceration, 
rather be compared to certain ruptures of the uterus? 
Both one and the other take place during the con- 
traction of the organ: both one and the other suppose 
a primitive alteration of this same organ : a defect of 
any resistance; such as that produced by softening, 
for example. It is precisely because the ruptures of 
the heart take place at the moment of the contrac- 
tion, that wc can explain one of the most remarkable 
circumstances, namely, their greater frequency in the 
left ventricle ; that is to say, in the most robust part 
of the organ, and also, because it contracts with the 
greatest energy. The rupture ordinarily takes place 
towards the apex, the thinnest and least resisting po- 
sition of the ventricle. When it forms in any other 
part of that cavity, it is undoubtedly in consequence 
of some particular circumstance, that cannot always 
be easily determined. 

Enough has been already said on a disease, the di- 
agnosis of which is very obscure, and the existence 
of which frequently is not manifest until it has pro- 
duced sudden death. * In the mean time, let us throw 
aside all that has been said on this form of carditis, 
and turn our attention to the study of those which are 
characterized by the softening or inclination of the 
muscular texture of the heart. 

* Out often patients who died of rupture of the heart, eight expired in- 
stantly, one in about two hours, and another in about fourteen hours. (Revm 
Medicate, article par M. Bayle, No. dcJuilkt.} 



DISEASES OF THE HEART. 391 

ARTICLE I. 

OF THE SOFTENING OF THE HEART, (CARDITIS.) 

SECTION I. 

M. Laennec is the first author, in France at least. 
who has given particular attention to the softening of 
the heart; but he has not considered it in the same 
point of view that we have regarded it here. With 
few exceptions, in this particular, our views corres- 
pond with those of M. Laennec. We have ascer- 
tained, as well as he, that there are two species of 
softening, the one with a deeper colour of the sub- 
stance of the heart, the other discoloured, or rather 
with a whitish or yellowish colour of that substance. 
The first kind coincides with the symptoms of acute 
disease, whilst the other frequently accompanies chro- 
nic diseases. Thus, we have observed the red soft- 
ening, which may be called acute, in fevers of a grave 
or very dangerous tendency: whilst we have collect- 
ed examples of white or yellow softening, which 
we have designated by the term chronic, in indivi- 
duals who have died of slow or hectic fever. Most 
of the cases contained in our first chapter, and espe- 
cially the fifth, sixth, seventh, eighth, ninth, eleventh, 
thirteenth, sixteenth, twenty-fourth, twenty-fifth. 
twentv-sixth, many of those contained in the first 
chapter of the first section of the second book, the 
sixtv-sixth and sixty-seventh, particularly, are ex- 
amples of inflammatory softening of the heart. We 
might here relate other examples, if space would per- 
mit. We have compared the softening and loss of 



392 DISEASES OF THE HEART. 

cohesion of the texture of the heart to the softening 
of the brain, liver, uterus, spleen and kidneys, which 
is generally regarded in the present day, as a sure 
character of inflammation of those organs. Conse- 
quently, we ought to consider the softening here as 
an equally positive symptom of carditis. We cannot 
adopt any other opinion, without disturbing the laws 
of analogy. M. Laennec compares the softening of 
the heart coinciding with essential fevers to the ad- 
hesive softening of the muscles observed in those dis- 
eases, and especially in adynamic or putrid fevers, 
but he does not give it as one of the characters of in- 
flammation. " I would not dare affirm," says he, 
" that this softening takes place in all idiopathic fe- 
vers; nevertheless, I have met with it, in every in- 
stance, in those cases where I have made an attentive 
examination."* The remarks we have made in the 
first chapter of this work fully confirm those of M. 
Laennec. The same author adds, — " Will it be said, 
that the softening is the cause of the extraordinary 
frequency of the pulse which frequently supervenes 
in the convalescence of fevers, and which continues, 
in some cases, for many weeks, although the patient 
recovers his strength and flesh?" It seems to us that 
we might reply in the affirmative to this question : 
and this reply appears very natural in admitting with 
us that the softening of the heart is, in fact, carditis, 
whilst, in every other mode of observation, it would 
be difficult to give an account of this remarkable phe- 
nomenon; that is to say, the acceleration of the pulse, 
and, consequently, the contractions of the heart. 

* De PAuscult torn. ii. page 290. 



DISEASES OF THE HEART. 393 

If we were called upon to demonstrate the relation 
which exists between aortitis and the dilatation of the 
aorta, it would be soon manifest that a similar relation 
might exist between the softening of the heart, and 
the aneurism of that organ, and that the first lesion is 
indubitably favourable to the formation of the other/ 
because softening weakens the cohesion, and, conse- 
quently, the resistance of the muscular fibres of the 
heart, and this resistance is evidently a predisposi- 
tion to dilatation. 

SECTION II. 

The anatomical characters of softening of the 
heart are the following: the fleshy texture of the 
heart is almost entirely deprived of its coherent 
power; it is friable and soft, and may be torn with 
the greatest facility, by merely pressing it slightly 
between the fingers. The parietes of the ventricles 
are flabby, and fall inward after incision, even in those 
cases in which they are hypertrophied, or rather 
thickened. In general, at the same time that the 
muscular substance of the heart is softened, it be- 
comes also changed in colour; sometimes it is found 
of a deep red or even brownish colour, which appears 
to us to indicate acute carditis; at other times, on the 
contrary, the muscular substance is discoloured, be- 
comes pale or yellow; a sort of colour which has been 
justly compared by M. Laennec to that of dead leaves: 
this constitutes chronic carditis. 

The softening of the heart is either general or par- 
tial, and may be complicated with all the other ana- 
tomical lesions with which we have been already oc- 

50 



394 DISEASES OF THE HEART. 

cupied. It appears to us, that it is never found in- 
dependently of a pathological affection of the exter- 
nal or internal membrane of the heart. 



SECTION III. 

If softening of the heart be always the consequence 
of phlegmasia of the internal or external membrane 
of that organ, its causes ought to be the same as those 
of the latter disease. Perhaps the muscular texture 
of the heart may be primitively inflamed; but this is 
somewhat difficult to understand, and requires farther 
research. 

SECTION IV. 

The symptoms of softening of the heart have not 
as yet attracted the attention of physicians. These 
symptoms are nearly the same as those of pericardi- 
tis. When the softening is the effect of an acute 
phlegmasia, we may observe a great degree of anx- 
iousness, a precipitous, small, weak, profound pulse; 
a tendency to lypothymia, as in cases of acute peri- 
carditis.* Patients sometimes die suddenly. When 
the softening is, on the contrary, the result of chronic 
inflammation? the patients are in a state of cachexia 
and languor, the face is discoloured and wrinkled; 
their strength is exhausted; the pulsations of the heart 
and of the pulse are frequent, but soft and without 

* Wc know that in cases of acute pericarditis, some arc not accompanied 

with alarming symptoms, while others are marked by the most distressing- phe- 

. nomena. Would it be unreasonable to suppose that this difference is owing 

to the circumstance that in the latter the phlegmasia is propagated to the 

muscular texture of the heart, which would not have occurred in the first. 



DISEASES OF THE HEART. 395 

vigour. Serous infiltration supervenes, accompanied 
with other symptoms which denote obstruction to the 
circulation. We ought to remark, that, in every in- 
stance, the symptoms of cachexia are very frequent- 
ly produced by a chronic disease of which carditis 
itself is only one of the alarming consequences. 

If we explore attentively the contraction of the 
heart in those cases in which it is softened, we shall 
observe that they are accompanied only with a very 
feeble impulse, sometimes hardly appreciable, and 
that the sound is more dull, more obscure and more 
obtuse than in the natural state. The contractions, 
when the softening is acute, are quick, precipitous, 
and almost convulsive; when this softening is chro- 
nic, they lose their vivacity, and we find them some- 
times precipitous, sometimes slow, as we have espe- 
cially observed in one of our patients in whom these 
alternations were manifested in a most striking man- 
ner. 

SECTION V. 

Softening of the heart is, ordinarily, a consecutive, 
and, in some measure, a symptomatic disease: its prog- 
nosis relates to the nature and intensity of the affec- 
tion by which it is produced. Thus, it would be very 
different, according as it should be determined by an 
essential fever, acute or chronic, or by a scorbutic 
affection. The softening which accompanies peri- 
carditis adds much to its severity. 



396 DISEASES OF THE HEART. 

SECTION VI. 

The softening of the heart produced by an idiopa- 
thic phlegmasia of that organ requires absolutely the 
same method of treatment as pericarditis;* as to that 
which is symptomatic, it is evident that its treatment 
is in some measure included in that of the principal 
disease, and therefore we shall speak of it here. 



ARTICLE II. 

OF THE HARDENING OF THE MUSCULAR SUBSTANCE OF 
THE HEART. 



SECTION I. 

Many observers have collected examples of hard- 
ening of the muscular substance of the heart. Al- 
bertini has seen a case of ossification of one of the 
auricles; Corvisart once found the substance of the 
heart so hard, that it resounded like a horn, although 
it preserved its red colour; at another time, he met 
with a cartilaginous hardening of the apex of the 
heart. Burns had an opportunity of seeing the tex- 
ture of the ventricles perfectly ossified, so as to re- 
semble the bones of the cranium. M. Renaulden com- 
municated to Corvisart, a short time before his death, 
the case of a kind of petrifaction of the heart. We 
have ourselves met with various cases of induration 
of the heart; and have, in the preceding pages, re- 
ported the case of an individual in whom we found 

* See the first chapter of the first section. 



DISEASES OF THE HEART. 397 

an ossification towards the apex of the heart, and that 
of a young man in whom a lardaceous and fibro-car- 
tilaginous induration of the pericardium involved the 
proper texture of the heart: we shall now give some 
extracts from other analogous cases. 

Case XCII. 

•ftneurismal Hypertrophy, with Hardening of the Right 
Ventricle, and fibrocartilaginous formation of the 
Mitral Valve. 

Louis Neuray, thirty-three years of ag;e, died at 
the hospital Cochin, the 9th of January, 1823, after 
having presented all the symptoms of contraction of 
the orifices of the heart with hypertrophy of the right 
ventricle.* Among these symptoms, the most re- 
markable were the following: we heard, during the 
contractions of the auricles, the bellows sound; the 
right ventricle was perceived to beat with great vio- 
lence; the pulsations repelled the hand, or the cylin- 
der when applied to the region of the heart: the pa- 
tient complained of strong palpitations, and she could 
very well distinguish that they were more developed 
at the right than the left side. On opening the body, 
we found the right ventricle of the heart a third 
larger than in the natural state; the dilatation was for 
the most part towards the insertion of the pulmonary 
artery; the parietes of the ventricle were from three 
to five lines in thickness; their texture was of a rose 
red colour, of remarkable consistence, and in a state 
of almost cartilaginous induration. 

* This disease appeared to have been the result of a fall on the precordial 
region. 



398 DISEASES OF THE HEART. 



Case XCIII. 



A gardener, forty-eight years of age, died at the 
hospital Cochin, the 21st of January, 1820, with 
symptoms which announced great obstruction of the 
circulation. The right ventricle was considerably 
dilated; the columnse were enlarged, and such was 
their density that in pulling them strongly in oppo- 
site directions they seemed to break rather than tear. 
The parietes of this ventricle were thicker than na- 
tural, and presented the same hardening as the co- 
lumnse carnese: its internal surface was very red; the 
ventricular septum was much thickened, and while 
the half of this septum, appertaining in some measure 
to the right ventricle was hardened, the other half, 
corresponding to the left ventricle, preserved its 
usual density. 

Case XCIV. 

Hardening of the left Ventricle, Softening of the right, 
Alteration of the Valves. 

A woman about fifty years of age, was brought to 
the hospital Cochin, where she died in a few hours. 
Her pulse was scarcely perceptible, irregular, and 
intermittent; and when the hand was applied over 
the precordial region, the pulsations of the heart, in 
a space somewhat circumscribed, were found to be 
abrupt and accompanied by a purring tremor : the 
face was injected. The heart was of considerable 
size : the parietes of the right ventricle were a little 
thicker than in the natural state; they were soft and 
easily torn; the left ventricle presented such firm- 



DISEASES OF THE HEART. 399 

ness and resistance to the touch, that any person 
would have supposed that they were pressing upon 
bone or some similar substance: its parietes were 
about two fingers' breadth in thickness, and its cavi- 
ty, almost obliterated, was filled with a polypous con- 
cretion, as large as a small leech. 

Case XCV. 

Hardening and Softening of the left Ventricle of the 

Heart. 

A professor of belles-lettres, having what is vague- 
ly called aneurism of the heart, died at the hospital 
Cochin the 13th of October, 1822. The left ventri- 
cle was dilated and thickened, the texture of its co- 
lumnar earnest was altered, of a yellowish white co- 
lour, hard and resisting in some parts, soft and easily 
torn in others: the discolouring of the columns con- 
trasted with the bright red texture of the parietes, 
which were likewise a little softened; the internal 
membrane of the heart was red. 

SECTION L 

Hardening of the muscular substance of the heart 
presents many degrees or shades, if we may be per- 
mitted to use such an expression : hypertrophy with- 
out complication is in some measure a rudiment of 
induration, whilst ossification and petrifaction consti- 
tute its last degree. Between these two extremes 
we meet with various shades : sometimes the substance 
of the heart, of a rose red colour, almost healthy in 
appearance, approaches the hardness of fibro-carti- 



400 DISEASES OF THE HEART. 

lage, resists and grates on incision; sometimes it of- 
fers a density and solidity truly cartilaginous; at other 
times it is harder, and resounds like a horn, accord- 
ing to the expression of Corvisart. Sometimes the 
hardened substance is of an earthy or sandy consis- 
tence. 

We have never had an opportunity of observing a 
general hardening of the heart, but it may be more 
or less extensive, and sometimes involve nearly the 
whole of the heart; it is frequently confined to the 
internal or the external surface of the heart, where 
it occurs in the form of incrustations:* the columnar 
carnese may be the exclusive seat of them; the same 
may also be said of the septum. In a case of cartila- 
ginous hardening of the right ventricle, in our col- 
lection, only half of the septum corresponding to that 
ventricle was affected. Hardening may either exist 
with a natural state, an enlargement, or a diminution of 
the affected cavity. It is frequently accompanied with 
thickening of the parietes. It is rational to suppose 
that induration of the heart takes the same course as 
induration of the aorta and its valves, which we have al- 
ready spoken of, and passes through the same changes: 
a minute description of all these accidental changes 
of texture would lead us beyond our present design. 

SECTION II. 

The symptoms of hardening of the heart necessa- 
rily vary according to the degree and the extent of 

* In many cases the induration of the muscular substance of the heart ap- 
pears to have been produced by the extension or propagation of a similar 
induration of the pericardium. 



DISEASES OF THE HEART. 401 

the evil. When the hardening is in the first degree, 
the substance of the heart does not present any sensi- 
ble change in its external characters, and the symp- 
toms are the same as those of hypertrophy. But it 
will be perceived that the activity and energy of the 
pulsations of the heart, must diminish in exact propor- 
tion to the progress of the disease, and that an impos- 
sibility of alternate contraction and dilatation, must be 
the inevitable result of an induration which should 
entirely change the nature of the muscular substance 
of the heart. It appears that the heart, with a mo- 
derate degree of induration, retains a great power of 
contraction. It has been ascertained, almost cer- 
tainly, that an osseous or cartilaginous induration of 
half, or the whole of any cavity of the heart, may be 
recognised by auscultation, and that it* must conside- 
rably increase the sound of the contractions of that 
organ. M. Laennec thinks, that, in cases of this na- 
ture the sound of the heart may be heard by the naked 
ear,* and even at a certain distance from the patient. 
In the case of hardening recorded by M. Renaul- 
din, " the hand applied on the region of the heart 
perceived a kind of separation of the ribs, and when 
this region was even moderately pressed it occasioned 
very acute pain, which continued a long time after 
the compression." In one of our patients, the heart 
contracted with such a powerful impulse that the 
chest was shaken in its whole extent, f 

* The sound of the heart may be heard by the ear alone in every case 
where it can be heard by the cylinder. 

•J- Our observations perfectly agree with those of M. Laennec on this 
point. He says, in fact, that the firmest hearts he had met with were also 
those which gave the strongest impulse. This is, undoubtedly, the reason 
why he was led to consider the first degree of induration of the heart as the 

51 



402 DISEASES OF THE HEART. 

Farthermore, it is evident that the symptoms of 
hardening of the heart receive important modifica- 
tions according to the various complications which 
may exist, the most of which have been noticed in 
the preceding chapters. 

SECTION III. 

The treatment of the active hardening of the heart 
must evidently be grounded on that recommended for 
the nutritive irritation of the heart; but, in the case 
of passive hardening, when the heart is converted 
into a cartilaginous or osseous substance, and is inca- 
pable of performing its functions, it is very certain 
that a cure cannot be expected, and that palliative 
measures are all the physician can rely on. 



ARTICLE III. 

OF GANGRENE, OR SPHACELUS OF THE HEART. 

Gangrene of the heart is one of those affections the 
existence of which may possibly be conceived; but 
this disease is so rarely met with, that it has been 
questioned by several physicians whether it really 
exist: the most illustrious observers have never met 
with it. Considered as one of the terminations of in- 
last of hypertrophy ,| Corvisart thinks that this induration causes the con- 
traction of the venbicles to be more difficult, and their movements more 
confined, which is true of one degree of the disease, but not of all. 

| JluscuU* torn. ii. p. 286. 



DISEASES OF THE HEART, 403 

flammation of the heart, it is not difficult to compre- 
hend the reason of its infrequency. In the first place, 
it may be said, in general, that of all the textures of 
the human body the muscular is one of those the least 
susceptible of the development of gangrene; in the 
' second place, sub-acute inflammation of the heart is 
so serious a disease, and so rapid in its course, that it 
kills the patients before the gangrene has had time, 
as it were to declare itself: this accident, then, may 
rather be the effect of a malignant cause, to use the 
expression of the ancients, than of any violence like 
that of carditis. Corvisart, also, does not hesitate to 
advance that any well authenticated instance of gan- 
grene of the heart does not exist. Various authors, 
it is true, and Senac among others, who speak of pu- 
trid hearts, entirely decayed, &c, have not hesitated 
to report many examples of such a disease, but such 
facts are usually investigated in the most careless 
manner, and ought not to be received until after close 
examination, nor admitted but with prudent caution. 
These are the cases in which it is proper to confine 
ourselves within the bounds of philosophic doubt. 
If we consider with an attentive and unprejudiced 
mind the observations on gangrene of the heart col- 
lected by Deidier, J. Baukin, M. Geroux, we shall 
perhaps see that they may be more naturally ar- 
ranged among the examples of acute softening of the 
heart, than among affections truly gangrenous. Our 
twenty-sixth case itself, in which the heart was soft, 
flabby, of a brownish colour, and almost putrid, does 
not appear to us conclusive, and gave rise to the same 
doubt as the preceding; because this kind of soften- 
ing of the heart may have been nothing more than a 



404 DISEASES OF THE HEART. 

softening, which the commencing putrefaction of the 
subject had transformed into a gangrenous state. It 
is much better to resolve to support the doubtful side 
of a question than to expose oneself to the hazard of 
mistaking a cadaveric phenomenon for an organic 
and pathologic lesion. Gangrene of the heart, if it 
be true that it really exist, is too far beyond, all the 
resources of art, that we should propose any advice 
respecting its treatment here. 



DISEASES OF THE HEART. 405 



CHAPTER V. 

OF CANCER, AND THE OTHER ACCIDENTALPRODUCTIONS 
OF THE HEART, WHICH HAVE NOTHING ANALOGOUS IN 
ANY OF THE OTHER TEXTURES OF THE ANIMAL ECO- 
NOMY. 

In placing the history of cancer of the heart after 
inflammatory softening and gangrene of that organ, 
we do not wish it to be understood that we establish, 
as some authors have done, a kind of resemblance be- 
tween gangrene and cancer, nor that we think, with 
others, that cancer is nothing more than a phlegma- 
sia: such is not our opinion. In inflammation, there 
is an exaltation of the organic properties; in gan- 
grene, there is an abolition of these same properties: 
but cancer does not consist of either one or the other 
of these states : it is, in fact, a perversion of the or- 
ganic properties, from which results the production 
of a morbid accidental tissue which has nothing ana- 
logous in the animal economy, and could not have, if 
it be true that its formation is not governed by the 
same laws as those which take precedence in organo- 
geny, properly speaking. Farthermore, cancer of 
the heart is a disease so rare, that the most distin- 
guished pathologists have never witnessed examples 
of it. However, MM. Recamier, Bulhier, Cruveil- 
hier, and some others, have stated the existence of 
this cancer, of which M. Carcessone had already 



406 DISEASES OF THE HEART, 

given a description in the Memoir es de la Societe 
Hoy ale de Medicine, for the years 1777 and 1778. 
Finally, three new cases of this disease, collected by 
MM. Andral and Bayle, have been very lately pub- 
lished in the Revue Medicate. In the first patient, 
the cancer occupied the ventricle and auricle of the 
right side, and was complicated with hypertrophy of 
the left ventricle. ,The symptoms observed, says M. 
Andral, were those which usually accompany aneu- 
rism of the heart. According to the same author, 
the individual died in consequence of hypertrophy, 
and not of cancer of the heart. M. Andral thinks, 
also, that if the cancer had not been complicated with 
hypertrophy of the left rarities, it would not have 
disturbed the circulation in a special manner. What 
a singular opinion! He is not willing that the cancer, 
that is to say, the disorganization of the heart, should 
be an obstacle to the circulation, and yet he regards 
as such the hypertrophy, that is to say, the augment- 
ed energy of the heart! We have proved, elsewhere, 
how erroneous such an opinion must be; and M. An- 
dral would not have embraced it, if he had not taken 
it, as it were, on trust, without submitting it to his 
judicious and profound mind. It is farther evident, 
that the patient in question died, for the most part, 
in consequence of an ossification of the aortic valves, 
an alteration of which the aneurism and hypertrophy 
of the heart were only the efFects. and which was the 
true cause of the embarrassment of the circulation. 
In the second case reported by M. Andral. the can- 
cer was again situated in the right side of the heart. 
Lancinating pains at intervals, dyspnera. progressive 
wasting of the body, and at last anasarca, were tin 






DISEASES OF THE HEART. 407 

principal symptoms observed. In the third case, 
which appertained to M. Bayle, the cancer affected 
the two auricles and the interventricular septum; no 
local symptom was observed, and nutrition itself con- 
tinued unimpaired. The patient, however, died. 

From the preceding facts, which M. Andral has 
kindly communicated to us, he concludes, "that it 
is evident that the muscular fibres of the heart may 
be in part destroyed without any remarkable distur- 
bance of the circulation; that in no case was death 
the result of an influence exercised by the heart on 
the circulation; that, in the first case, death was 
owing to an aneurism of the heart." {M. Jlndral, 
in the first instance, considered hypertrophy as the 
cause of it : it is clear, however, that he confounds 
hypertrophy and aneurism with each other, although 
very different affections, as we have elsewhere ex- 
plained.} " That, in the second case, it was in con- 
sequence of a change of nutrition that the cancer in- 
duced the death of the patient." M. Andral does 
not say how death happened in the third case; and 
we must acknowledge that it would be difficult to 
state it, after an attentive reading of the case.* M. 
Andral terminates, likewise, by allowing that the 
facts which he has reported are not sufficiently nu- 
merous to enable him to trace the general history of 
cancerous affections of the heart: we cannot termi- 
nate our own remarks by a more wise and judicious 
reflection. 

Cancer is not the only accidental production to be 
met with in the heart; there has also been found tu- 

* We would request the reader to examine the opinions of MM. AndraJ 
and Bayle, inserted in the Revue Medicale, (cahier de mai.) 



408 DISEASES OF THE HEART. 

bercular matter, serous cysts, and vesicular worms. 
Some of the ancient observers pretend that they 
have even met with worms; but this remark origi- 
nating in times when the love of the marvellous fre- 
quently distorted the truth, must be placed by the 
side of those which speak of hairy hearts, hearts filled 
with lice, serpents, vipers, &c, and by the side of 
so many others, whose authors, as it were, cause na- 
ture to lie, instead of being the sincere interpreters 
of it. 

We have referred the cartilaginous, osseous, and 
other analogous productions which may be found in 
other parts of the system, to the consequences and 
terminations of inflammation; we shall not, therefore, 
reconsider them here. 



DISEASES OF THE HEART, 409 



section m. 

DISEASES OF THE VESSELS OF THE HEART. 

The vessels of the heart are subject to all the dis- 
eases of the vascular system in general. We shall 
proceed to give a rapid sketch of all that medical in- 
quiry has collected on this part of the pathology of 
the heart. 

SECTION I. 

DISEASES OF THE ARTERIES OF THE HEART. 

The coronary arteries are susceptible of inflamma* 
tion, like all the rest: we have sometimes found their 
internal membrane red; and, in their parietes, the 
same alterations which we have described when speak* 
ing of aortitis, that is to say, calcarious scales, and 
cartilaginous laminse, &c. In a case reported in ano- 
ther part of this work,* the coronary arteries were 
ossified in their whole extent, and somewhat resem- 
bled branches of coral. We are in possession of a 
case of obliteration of one of these arteries in conse- 
quence of a complete ossification of its parietes. 

We have also met with general dilatation of these 
arteries. In one case of hypertrophy of the left ven- 

* Case LXXVni. page 298. 
52 



410 DISEASES OF THE VESSELS 

tricle, we found the left coronary artery so much en- 
larged, that its caliber was double that of the right 
coronary.* We have not had occasion to observe 
ulceration, rupture, or false aneurism of these arte- 
ries. 

Many physicians, especially in England, have re- 
garded ossification of the coronary arteries as the 
cause of angina pectoris, or stenocardia; but taking 
as our guide exact and rigorous observation, it is im- 
possible to refer the symptoms which characterize 
angina pectoris to any lesion of the heart exclusive- 
ly. We have seen these symptoms accompanied with 
a multitude of different organic affections, either of 
the heart, or of the large vessels, or even of the 
lungs. Hence the reason why Heberden, Wichmann, 
Parry, Burns, Testa, Kreisig, Brera, Averandi, Ju- 
rine, Desportes, &c, who have paid particular at- 
tention to the study of this disease, do not in the least 
agree respecting its seat and nature. f Some will 
have it that angina of the chest depends on an ossifi- 
cation of the coronary arteries; others consider it as 
a symptom of compression of the heart by the neigh- 
bouring organs, and even by the abdominal viscera : 
some of them refer it to a neurosis of the pulmonary 
nerves, others to a neurosis of the cardiac plexus, 
&c. Perhaps each of these authors are right and 
wrong at the same time : right, because stenocardia 
may be really produced by the organic cause as- 
signed to it; wrong, because this cause, though real, 

* Case LXXIV. 

\ Every one knows that the principal symptoms of angina pectoris are a 
sense of constriction of the chest, pain in the region of the heart, and in the 
left arm, anxiety, suffocation, and extreme pain, occurring most commonly 
in paroxysms. 



OF THE HEART. 411 

is not the only one which may give rise to the dis- 
ease in question. But, without engaging in a diffi- 
cult discussion, we shall content ourselves with ob- 
serving here that ossification of the coronary arteries 
cannot be considered as the constant cause of angina 
pectoris, since we have proved its existence in sub- 
jects who had not presented any symptoms of steno- 
cardia, and because other physicians have made the 
converse remark, that they have met with angina 
pectoris without any ossification of the coronary ar- 
teries. 

In the actual state of science, we cannot say pre- 
cisely what are the effects of ossification of the co- 
ronary arteries; but w r e think we can hazard the 
opinion, that in certain cases its effects are totally 
inappreciable. 

SECTION II. 

DISEASES OF THE VEINS OF THE HEART. 

We may say Of the veins what we have said of the 
coronary arteries, namely, that their diseases must 
necessarily be the same as those of the venous system 
in general. The diseases of the veins of the heart 
are either very unfrequent, or have been badly ob- 
served, for few examples are found among authors : 
the only one which we ourselves have frequently ob- 
served, is a kind of varicose dilatation of these ves- 
sels. This dilatation is observed in cases where the 
circulation has been a long time, and considerably 
obstructed, and coincides with dilatation or aneurism 
of the heart. We can readily comprehend the me- 
chanism of this affection of the cardiac veins. The 



412 DISEASES OF THE VESSELS 

blood distending the cavities of the heart, and espe- 
cially of the right auricle, does not permit the blood 
contained in the veins of the heart to discharge it- 
self freely into that auricle : it accumulates, there- 
fore, in their cavity, and swells them to the utmost 
extent. From this results venous turgescence, and, 
if we may be allowed the expression, a sub- apoplectic 
state of the heart's texture. We have seen the veins 
ruptured, in consequence of the excessive congestion 
and extreme distention of the parietes. Besides, this 
lesion of the cardiac veins is not so much a special 
disease as the symptom of a more severe affection: it 
will be sufficient that we have alluded to the disease, 
and shown its anatomical characters, the symptoms 
and treatment of which are confounded with the 
symptoms and treatment of obstructed circulation, 
from whatever cause produced. 

SECTION III. 

The diseases of the lymphatic vessels of the heart 
are entirely unknown. 

SECTION IV. 

OF THE DISEASES OF THE NERVES OF THE HEART, SUCH 
AS PALPITATIONS, CARDIALGIA, SYNCOPE, OR PARALYSIS 
OF THE HEART. 

The nerves of the heart, which should be regard- 
ed as the spring and principal agent in the living 
movements of that organ, cannot long remain unaf- 
fected with the various diseases by which it may be 
attacked; but it is of less consequence to examine in 



OF THE HEAHT. 413 

this place what part the nervous system of the heart 
performs in these diseases, than to bring into view 
the diseases which primarily affect the nervous plex- 
uses of the heart, and the influence of which must 
necessarily be imparted to its contractile tissue; for 
the researches of physiologists have informed us, that 
this organ acquires the principle of motion from 
the nervous ganglionic system. Now, the nerves of 
the heart, like those of all the other organs, are sus- 
ceptible of two modes of vital lesion; namely, an in- 
creased or diminished sensibility, or rather irritabi- 
lity, with which they are endowed, from whence we 
may trace the active nervous affections arising from 
an excess of stimulus; or passive nervous affections 
from the want of this irritability. 



I. NERVOUS AFFECTIONS OF THE HEART. 

To this class of nervous affections we may refer 
palpitations, spasm, convulsions of the heart, and 
neuralgia of that organ. 

SECTION I. 

OF PALPITATIONS, OR IRRITATION OF THE NERVES OF THE 

HEART. 

Every palpitation supposes some irritation of the 
nerves of the heart, since the first are the principal mo- 
vers of the second; but nervous palpitations, properly 
speaking, are distinguished from others in this, that 
they depend on a direct excitation of the nerves, and 
cannot be attributed to any appreciable lesion of the 



414 DISEASES OF THE VESSELS 

heart; whilst the others, that is to say, the secondary 
or sympathetic palpitations, coincide essentially with 
a material and sensible alteration of that organ. 

Nervous palpitations, like all other palpitations of 
the heart, consist of an augmented intensity or fre- 
quency, or simultaneous intensity and frequency of 
the natural contractions of that organ; of such a kind, 
that its contractions, which are made without our 
knowledge in the state of health, become not only 
very sensible, but also very importunate to the pa- 
tient. There is another kind of palpitation, which 
does not enter into the preceding definition, which 
is characterized by a precipitation of the pulsations 
of the heart without any increase or diminution of 
their energy. The degrees of intensity of the pal- 
pitations are almost infinite, from those which are 
scarcely to be perceived, to that spasmodic convul- 
sive contraction during which the heart may be 
broken, as the voluntary muscles sometimes are when 
they contract with excessive violence. 

The symptoms of nervous palpitations, are, to a 
certain degree, vegetative; that is to say, they are 
to be distinguished by the quick, strong, tumultuous 
contractions, not accompanied by any of those phe- 
nomena which announce a material or organic dis- 
ease of the heart. The patient can hear very dis- 
tinctly the alternate sound of the movements of the 
heart: when he lies on the side, they are often very 
inconvenient. He can perceive also in the palpita- 
tions those abrupt and violent shocks complained of 
in the precordial region. The physician, farther- 
more, in forming a diagnosis of palpitations, can make 
use of three of the senses, touch, hearing, and sight; 



OF THE HEART. 415 

and, according to the definition given of this disease, 
the symptoms furnished by these different modes of 
exploration might be anticipated. We shall, there- 
fore, pass immediately to the causes of palpitations. 

The causes of this affection are very numerous. 
The predisposing are a nervous, sanguine, or ple- 
thoric temperament. The active causes are, pas- 
sions of the soul, such as anger, joy, love, surprise; 
violent exercises, running, dancing, and venereal 
excesses, stimulating ingesta, such as spirituous li- 
quors, tea, coffee, &c, are also agents which must be 
ranked among the causes of palpitations. Finally, all 
of these causes respectively determine palpitations, 
first, by irritating directly the nervous plexuses of the 
heart, as happens in the active affections of the soul; 
or, secondly, by stimulating them indirectly, as occurs 
in violent exertions, and from using exciting aliments; 
the first accumulate in the heart a too large quantity 
of blood, its natural stimulant,* the second augment 
the exciting properties of that fluid. Agreeably to 
these opinions, palpitations may be divided into ner- 
vous and sanguineous; the former class originating 
* in the immediate irritation of the nervous system, 
the latter in the quantity or the quality of the blood 
flowing into the cavities of the heart. There are also 
mixed palpitations, which depend at the same time 

Ion a primitive excitement of the cardiac nerves, and 
an indirect excitement of them by plethora, or by 
the irritating properties of the blood passing through 
* To the palpitations of the heart produced by plethora we can oppose 
those produced by profuse hemorrhage: because that organ palpitates alike, 
whether a part of its natural stimulus be removed, or too large a quantity 
be received. 



416 DISEASES OF THE VESSELS 

it. The palpitations which accompany the material 
diseases of the heart, the organic palpitations, if it 
be permitted us to use such an expression, are mani- 
fested under the influence of one of the conditions 
pointed out; namely, congestion of blood in the cavi- 
ties of the heart. When we regard the intimate na- 
ture of the phenomena, and consider that the distinc- 
tions established between them, are founded on the 
diversity of their causes only, or rather on the dif- 
ferent modes by which these causes arrive at the 
cardiac plexuses, to establish an increase of stimulus, 
we are authorized to say, that there is really only one 
kind of palpitation. This excess of stimulation is 
the fundamental fact; the palpitations are the result 
of it, or, if you will, the symptoms. 

In fevers, whether primitive or consecutive of au- 
thors, in the febrile phlegmasia, the heart, if more 
or less irritated, precipitates its pulsations, and re- 
ally palpitates. This kind of palpitation might be 
distinguished by the term febrile. 

Palpitations are continuous or intermittent in their 
progress, accordingly as their causes assume either 
the one or the other of these types. Purely nervous 
palpitations, developed by the influence of some moral 
affection, or succeeding too violent exercise, are dis- 
sipated in a few moments after the cause which pro- 
duced them has ceased to act; they constitute not so 
much a disease, as an indisposition, or inconvenience. 
Intermittent palpitation is one of the phenomena at- 
tending several nervous diseases which have been 
distinguished by particular names; such as hysteria, 
hypochondriasis, and melancholy. Continuous pal- 
pitations deserve the most attention ; they are very 



DISEASES OF THE HEART, 417 

seldom purely nervous: they are most frequently as- 
sociated with some lesion of the heart; which, though 
without difficulty at the commencement, soon becomes 
of a serious nature, when neglected. Farthermore, 
what is called nervous palpitation, is itself the result 
of some organic lesion: this lesion, it is true, is hid- 
den from observation, because our senses, perhaps, 
are not sufficiently acute to perceive it; but, it no 
less certainly exists, for it would be absurd to sup- 
pose any disease whatever to exists without a lesion 
of the organs. 

The treatment of palpitations may be rationally de- 
duced, from the distinctions and relations which have 
just been established; therefore, it is evident, that the 
first indication is to ascertain and remove the cause 
of the malady, or combat the disease, of which the 
palpitation is only a symptom. If the palpitations 
be owing to a plethoric condition, blood-letting, and 
other antiphlogistic remedies must be employed; or, if 
the causes can be attributed to immoderate or violent 
exercise, or passions of the soul> we must strictly pro- 
hibit the one, and use every exertion to moderate the 
others. At this point begins the domain of psycolo- 
gical medicine; here the physician should follow the 
footsteps of Erasistratus, Boerhaave, Bouvart, and 
many other celebrated practitioners. The most ra- 
tional physical remedies, all the treasures of thera- 
peutics will be lavished in vain, as long as the phy- 
sician is unable to trace back the true source of the 
disease; and, as long as he has not treated by moral 
medicine, a disease whose origin is entirely of a mo- 
ral nature, of what consequence is it, in fact, that you 
'combat a symptom unceasingly, if you do not attack the 

53 



418 DISEASES OF THE HEART. 

cause which has produced it? Palpitations produced 
by the passions, moral palpitations, properly speak- 
ing, above all then, demand the medicine of the soul. 
Passion should be opposed to passion, when it is im- 
possible to procure for the patient the object of his 
desires, and the possession of which would be suffi- 
cient to relieve him at once, it is necessary to offer 
him all the means capable of diverting the passion 
which distresses him. The physician, at the same 
time, should not neglect any of the resources which 
the materia medica, or pharmacy may furnish him; 
he should combine the use of physical with moral an- 
tispasmodics : opium, digitalis especially, which ap- 
pears to have a specific tranquilizing effect upon the 
heart, music, castor, infusions of tilia and orange 
flowers, juleps, and their distilled waters, warm 
baths, and cold baths, if the patients can support 
them, &c. are so many therapeutic agents, to which 
we may resort with success. 

SECTION II. 

NEURALGIA OF THE NERVES OF THE HEART. 

We shall only allude to this disease, for we have 
never had occasion to observe it. It is little known, 
like all the neuralgias of the ganglionic nerves; a sys- 
tem from which the heart receives the greatest num- 
ber of its nervous filaments. Perhaps this neuralgia 
is of itself one of the causes which produce the dis- 
ease, to which has been given the name of angina 
pectoris, or stenocardia. 



DISEASES OP THE HEART. 419* 



II. PASSIVE NEUROSIS OF THE HEART.— SYNCOPE. 

A. We have seen the heart submitted to various 
modifying irritants, precipitate its pulsations, palpi- 
tate, struggle, as it were, to repel them : but, in the 
present instance, on the contrary, we have seen it 
lose its energy, relax its contraction, and fall into a 
state of stupor, the highest degree of which con- 
stitutes syncope, or paralysis of the heart. Many 
physical or moral agents are endowed with the pro- 
perty of weakening, or even completely extinguish- 
ing the contractability of the heart; such are what are 
called the depressing passions, narcotic poisons, as 
digitalis, hydrocyanic acid, and certain miasms, 
which prostrate, as it were, all the nervous powers : 
such as the plague, and certain malignant intermit- 
tent fevers, &c. 

B. The phenomena of syncope are those of sudden 
death, from which it differs only in this, that in the 
greater number of these cases, the patients may be 
restored to life : we say, in the greater number of 
cases, for there are some in which the syncope is 
followed by actual death. The individual suffering 
from syncope, first begins to feel an inexpressible 
uneasiness; his eyes become obscure, and covered 
with a mist, tinnitus aurium occurs; the face be- 
comes pale; the lips are discoloured; the mind is 
extinguished; sensation is obliterated; the whole body 
is chilled; and covered with sweat; the limbs fall 
like inert masses; the knees sink under the weight 
of the body; all the joints become bent; the pulse 
and respiration disappear; no external signs of life 



420 DISEASES OF THE HEART. 

remain; it seems, as it were, momentarily eclipsed. 
Nevertheless, the patient returns to himself, and 
awakes from the fainting death; sensation and mo- 
tion return, and he feels as if he were restored to 
life. Most generally, the syncope lasts but a few 
seconds, at other times it continues for several mi- 
nutes. In certain circumstances, happily very rare, 
it is prolonged for several hours, or even whole days; 
and we have seen this apparent death simulate so per- 
fectly the real death, that persons who have been found 
in this dangerous state of syncope, perfidious sleep, and 
too faithful image of death, have been buried. The 
sense of uneasiness and anxiety which we have given 
as one of the precursory signs of syncope, is not al- 
ways present: moreover, some persons, before they 
become ill, experience the most delightful sensations 
of tranquillity and voluptuousness. Montaigne, re- 
covering from syncope, regretted bitterly that he 
could no longer enjoy the luxurious existence which 
had procured him a temporary annihilation. 

C. The causes of syncope are exceedingly various, 
and are frequently of an opposite character. In like 
manner, according to the vulgar expression, some per- 
sons are overpowered with joy, pain, love or hatred. 
Violent physical pain, for example, that which acr 
companies peritonitis, the passions, the sensations 
produced by the sight of certain objects, or certain 
sounds, or certain odours, &c. may produce syn- 
cope.* A more direct cause of this disease consists 

* It is said, that the Roman ladies were affected with syncope whenever 
they breathed the odour of flowers, and were therefore not permitted to keep 
them in their apartments. Every day we hear among us of women being' taken 
sick at the sight of a spider, or a bat; and of some, whose nerves are so sus- 
ceptible that they are liable to the same accident at flic touch of a peach, or 



DISEASES OF THE HEART. 421 

in the abstraction of a more or less considerable quan- 
tity of blood ; thence the syncopes produced by he- 
morrhage, and even a simple bleeding. Great ob- 
structions of the circulation also suspend the action 
of the heart, and occasion fainting. Finally, every 
thing which can directly or indirectly extinguish 
momentarily the nervous power of the heart, is a 
cause of syncope. 

D. The syncope produced by diseases, whether of 
the heart, or of the other organs, is a symptom, ra- 
ther than a disease, and requires, besides the specific 
treatment of syncope, that which is appropriate to 
those diseases of which it is one of the most dreadful 
effects. Syncope of a purely nervous character, such 
as that which happens to hysteric women, convales- 
cents, &c. is not in the least dangerous. The least ex- 
citement, the impression of fresh air, effusions of cold 
water, the application of certain fragrant odours to 
the pituitary membrane, such as those by ether, eau 
de Cologne, ammonia, &c. and a thousand other sim- 
ple and popular measures, are sufficient to over- 
come it. 

a raspberry, or velvet, satin, &c. What is still more remarkable, some women 
fall into a fainting* fit without any obvious cause, and, as it were, at will. Un- 
doubtedly, syncope produces the same voluptuous effect in them which it 
did in Montaigne. 



422 DISEASES OP THE HEART. 



SECTION V. 

OF THE DISEASES OF THE CELLULAR TEXTURE 
OF THE HEART. 



SECTION I. 

The cellular fatty texture, which naturally enve- 
lopes the heart, may sometimes undergo a kind of 
hypertrophy, so as to form enormous masses, from 
the pressure of which that organ is, as it were, 
choked up. This kind of obesity of the heart has 
been observed by several pathologists, who have 
thought themselves authorized to regard it as the 
cause of serious disorders, and, in some instances, of 
sudden death. Corvisart does not deny the possibility 
of such effects; but, assures us, that in subjects where 
he had met with very fat hearts, he has observed no- 
thing which would prove this state to be pathologic; 
that is to say, capable of deranging the function of 
the organ to such a degree, as to produce disease. 
Our own observation corresponds with that of Corvi- 
sart ; it appears, that this accumulation of fat about 
the heart, is only a circumstance, favourable to the 
rupture of its muscular texture; which depends, no 
doubt, upon the interposition of fat between the 
fleshy fibres> separating and disuniting them, and 



DISEASES OF THE HEART. 423 

by pressure, occasioning an atrophy of the whole or- 
gan. It is very remarkable, indeed, that, in general, 
the parietes of hearts which are fat are very thin, and 
lose the firmness of their fleshy substance. We have 
related a case of rupture of the auricle, which oc- 
curred in a priest, whose heart was overloaded with 
fat. 

Obesity of the heart, is a state which does not ap- 
pear to be met with, excepting in persons endowed 
with considerable general fleshiness; we have, never- 
theless, seen hearts much more fat than natural, in 
.individuals of a very moderate degree of flesh. This 
condition spoken of, should not be confounded with 
what has been distinguished by the name of fatty de- 
generation of the heart. 

SECTION II. 

In this last named affection, the muscular texture of 
the heart is converted, according to M. Laennec, 
"into a substance which presents most of the physical 
and chemical properties of fat: it is an alteration per- 
fectly resembling that which Haller and Vicq-de' Azir 
have observed in the muscles."* Laennec has never 
seen this alteration, except at the apex of the heart: 
he has seen it resemble certain softenings of the heart; 
but, he thinks that we may distinguish them in this, 
that the part affected with fatty degeneration, when 
pressed between two folds of paper, soils them deep- 

* According to the researches of M. Beclard, the muscles are not suscep- 
tible of the fatty degeneration. They are simply atrophied and discoloured 
in that change, which has been called the fatty degeneration of the mus- 
cles. 



424 DISEASES OF THE HEART. 

ly.* We think we have observed the fatty degene- 
ration of the heart, to which M. Laennec alludes; 
but, we acknowledge that we have confounded it 
with the chronic softening, of which, perhaps, it is 
only a variety. 

SECTION III. 

We sometimes observe a state opposite to that which 
we have described under the denomination obesity or 
fatty hypertrophy of the heart; that is to say an atro- 
phy, more or less marked of the cellular membrane 
of the organ. This emaciation of the heart coincides 
with the general emaciation, which follows diseases 
of debility and consumption, such as phthysis pulmo- 
nalis, chronic diarrhoea, &c. 

SECTION IV. 

Lastly, we have not unfrequently found the fatty 
cellular texture of the heart in a state of serous infiltra- 
tion. This disease, to which we have given the name 
oedema of the heart is seldom simple and essential; it 
most frequently accompanies general dropsy, and may 
be attributed to the same general causes. We do not 
think that it has any peculiar signs: we can only sus- 
pect its existence in individuals affected with the se- 
rous diathesis, and who, notwithstanding, retain a 
good degree of flesh. This oedema has appeared to 
us to be always passive; that is to say consecutive to 
some obstruction of the venous circulation. 

We do not doubt but that the cellular texture of 
the heart may become inflamed like all the other tex- 

• De l'Auscult. Med, torn. ii. p. 298, 299. 



DISEASES OF THE HEART. 425 

tures; but we have never had occasion to observe this 
kind of phlegmasia, which does not appear to have 
been attended to by any with whom we are acquaint- 
ed : it can hardly be said to exist independently, and 
must, necessarily, be confounded with pericarditis or 
carditis. 



54 



426 DISEASES OF THE HEART, 



SECTION VI. 

OF THE DEFECTIVE CONFORMATION AND POSI- 
TION OF THE HEART. 



ARTICLE I. 

OF THE DEFECTIVE CONFORMATION OF THE HEART GENE- 
RALLY, AND OF THE COMMUNICATION OF THE RIGHT AND 
LEFT CAVITIES PARTICULARLY. 

The English, and especially the Germans, have 
devoted more particular attention than we have done 
to the various defective formations of the heart and 
large vessels. Burns arranges these monst?*osities 
into six species; viz. 

The First, in which the aorta arises from both the 
ventricles at the same time. It has been observed 
by Nevins in England, Sandifort, Stander and Tie- 
demann in Germany. 

The Second, in which species the foramen ovale 
and the canalis arteriosus remain open. It has been 
observed by a great many authors, and, among others, 
by M. Deschamps, MM. Fouquier and Thibert in 
France; and Messrs. Burns and Monro in England. 



DISEASES OF THE HEART. 427 

The Third, where the canalis arteriosus is oblite- 
rated, the foramen ovale remaining pervious. This 
variety has been observed by Morgagni, Hunter, Cor- 
visart, MM. Caillot, Jurine, Louis, &c, and three 
times by ourselves. 

The Fourth, consisting of a complete obliteration 
of the pulmonary artery, at its origin, which cannot 
receive blood, excepting by a retrograde action of 
the canalis arteriosus. It has been mentioned by 
Hunter; but his description is not perfectly satisfac- 
tory. 

The Fifth, in which the heart has only two cavi- 
ties, an auricle and a ventricle; and from the latter 
originates a vessel which divides into two branches; 
one of which conveys the blood to the lungs, and the 
other to the whole body. 

The Sixth, where the mitral valve represents a 
sort of plane perforated in the middle. It has been 
observed by Mr. Burns. We think that similar dis- 
positions maybe sometimes found in the other valves 
of the heart : we have met with them in the tricuspid 
valve, and in the valves of the pulmonary artery, as 
well as Morgagni and M. Louis. 

These several species, admitted by Burns, are far 
from including all the cases of vicious conformation 
of the heart and large vessels. We have seen, for in- 
stance, the aorta arise from the right ventricle, and 
the pulmonary artery from the left; we have seen, 
also, and M. Breschet has also shown us an example, 
of hearts with only one ventricle and two auricles.* 

* This defective formation has been noticed in the work of Kreisig 1 , Sur 
ks Maladies du> Cmur. 



428 DISEASES OF' THE HEART. 

Thus, Joseph Exupere Bertin relates, in his manu- 
scripts on angiology, that he found a double curva- 
ture of the aorta in a child from ten to twelve years 
of age. " The aorta," says he, " originated singly 
from the left ventricle, and afterwards divided into 
two branches, which again united to form the aorta 
descendens, nearly in the same manner as the two 
branches of a river unite with each other after having 
formed an island." Here then are three new spe- 
cies of monstrosities in addition to those mentioned 
by Burns. 

We may farther conceive that these species, by 
combining with each other, may form a great many 
others, which might be called mixed or compound. 
Whether this be true or not, of all the vices of con- 
formation the most frequent is that in which there is 
a communication between the different cavities of the 
heart; we shall, therefore, give a few moments' atten- 
tion to the subject. 

The communication between the right and left ca- 
vities of the heart most frequently takes place, in con- 
sequence of a permanent opening of the foramen 
ovale; this communication, however, is sometimes es- 
tablished in consequence of a congenital or accidental 
perforation of the septum of the auricles or the ven- 
tricles. We have even seen cases in which the four 
cavities of the heart communicated with each other, 
reciprocally, by means of a perforation existing at the 
junction of the auricular with the ventricular septum. 
Dr. Thibert has published an example in the Bulle- 
tin de la Faculte de Medecine (an. 1819.) 

Whatever be the mode of communication esta- 
blished between the right and left auricles: between 



DISEASES OF THE HEART. 429 

the pulmonary and aortic ventricles, or between all 
these cavities; whether the communication be conge- 
nital or accidental, one of the immediate effects of 
such an arrangement is the mixture of the arterial 
and venous blood. It may be difficult to conceive 
why this mixture does not take place in those 
cases where the communicating cavities exercise an 
equal force, and where the columns of blood, in at- 
tempting to traverse the opening of communication 
at the same time, oppose each other with equal force, 
and produce, as it were, an equilibrium; only, in 
these cases, which probably are very rare, the mix- 
ture would be much less marked than in those where 
cavities have unequal forces. But the circumstance 
most proper to effect this mixture, as M. Louis has 
remarked,* may be found in the obstruction expe- 
rienced by one of the columns of blood in passing 
through the channel, naturally fitted for it, as hap- 
pens when the orifices are more or less considerably 
contracted: a very common disposition, which may, 
perhaps, play an important part among the causes 
proper to determine the vicious conformation of which 
we are speaking. When the circumstance of which 
we have spoken exists, it is evident that the column 
of blood, the natural passage of which is found, as it 
were, intercepted, will increase the unnatural open- 
ing offered to it, and will pass through it with more 
or less facility in proportion as the cavity which con- 
tracts upon it, is endowed with an absolute or pro- 
portionate energy. The mixture of the red and 
black blood, the left and the right blood, is effected 

* See his memoir on this subject in the Archives Gener. deMedecine, t. Hi. 
num. de Novem. et Decern. 



430 DISEASES OF THE HEART. 

then during the systole of the heart. According to 
M. Louis, the same mixture takes place in all cases, 
during the diastole of that organ. But why does not 
the perfect equilibrium which M. Louis admits to ex- 
ist during the systole, when the opposite cavities have 
equal forces, exist during the diastole? We propose 
this question to M. Louis; because to us this equili- 
brium, whether during the contraction, or during the 
dilatation of the heart, seems to us much more fanci- 
ful than real, and, in our opinion, can only be consi- 
dered as a more or less probable hypothesis. 

However this may be, it is not absolutely necessa- 
ry that the effects of the mixture of the two kinds of 
blood should be absolutely the same in the right and 
the left cavities. Observation seems to have con- 
firmed what reason approves in this particular, since 
the reciprocal communication of the cavities of the 
heart is almost constantly accompanied with dilata- 
tion or hypertrophy of the right cavities, whilst these 
diseases are scarcely ever met with excepting in the 
left cavities. Hypertrophy of the right cavities, un- 
der the circumstances in question, is a phenomenon 
of which we have attempted to give an account when 
inquiring into the particular causes of hypertrophy 
of that side of the heart. We have said that the in- 
troduction of a certain quantity of red arterialized 
blood, in the right side of the heart, is well calcu- 
lated to determine hypertrophy, because it is more ir- 
ritating, more vivifying, more nutrient than the dark 
coloured blood which flows in the normal state only 
through the right cavities. If this explanation be not 
true, how does it happen that hypertrophy of these 
cavities is the constant accompaniment of their com- 



DISEASES OF THE HEART. 431 

munication with the left? The dilatation which we 
meet with, is undoubtedly the mechanical result of 
the passage of too large a quantity of blood into the 
dilated cavity, and perhaps, also, a too vivid impulse 
with which the blood is propelled from one of the 
communicating cavities to the other. Contraction, on 
the contrary, supposes that the cavity receives only 
a very small quantity of blood, or that this same ca- 
vity has lost its capacity, in consequence of the pro- 
gress of the hypertrophy from without inward, and 
consequently at the expense of this capacity. It is 
also necessary to take into account, in explaining hy- 
pertrophy and dilatation of the right cavities of the 
heart? the state of the corresponding orifices : now, it 
is very remarkable that of more than half the cases of 
communication between the left and right cavities of 
the heart, we find a contraction either of the ventri- 
culo- pulmonary orifice, or the pulmonary artery it- 
self. 

The symptoms which would lead us to recognise a 
communication of the opposite cavities of the heart 
deserve a careful consideration and inquiry: many 
physicians have attributed to this malformation, ex- 
clusively, a disease which they have denominated 
blue jaundice, blue disease, cyanosis. Such an opi- 
nion is entirely inadmissible, since we have in our 
possession cases in which cyanosis did not exist, al- 
though the right heart communicated with the left, 
and others where the cyanosis existed, although no 
communication was established between its parts; the 
least reflection, one would suppose, would be enough 
to make any one reject the opinion we have refuted. 
In fact, if the blue colour of the skin be produced by 



432 DISEASES OF THE HEART. 

the malformation in question, the same colour should 
be met with in every other part, which is contrary 
to observation: farthermore, according to an ingenious 
remark of M. Professor Fouquier, the skin of the foe- 
tus, which circulates only black blood, is not blue. 

It is very true, notwithstanding, that in certain in- 
dividuals, affected with a communication between the 
two hearts, we observe a bluish colour in certain 
parts, such as the lips, the ears, the face in general, 
&c. But this phenomenon admits of the same expla- 
nation as that we have exhibited when speaking of 
the obstructions of the circulation; that is to say, it 
depends on the stasis of the blood in the right cavi- 
ties, and in the venous system, which is in like man- 
ner distended. This explanation is so much the more 
rational, inasmuch as this malformation of the heart 
is most frequently accompanied with a contraction of 
the orifices, or, of the pulmonary artery itself. The 
other phenomena of the symptoms of a communica- 
tion between the right and left cavities of the heart, 
given by authors, are, more or less syncope, dimi- 
nished vital heat, sensibility to cold, suffocation more 
apparent than in the other diseases of the heart, a 
periodical suffocation, accompanied or followed by 
lipothymia, and provoked by very slight causes. We 
think that most of these symptoms are frequently, 
less the effect of an unnatural communication be- 
tween the opposite cavities of the heart, than that of 
the concomitant diseases, or contractions of the ori- 
fices. What leads us to think so, is that we have 
seen a case of the persistance of the foramen ovale, 
in which no symptom, which could properly indicate 
this lesion, appeared. 



DISEASES OF THE HEART. 433 

Finally, to enable us to pronounce with assurance 
on the value of the symptoms proposed, it is neces- 
sary that we should have observed the defective con- 
formation which occupies us in its state of simplici- 
ty, and this, it seems, has not hitherto been done. 

If this monstrosity constantly opposed so great an 
obstruction to the circulation, we should with diffi- 
culty conceive how individuals who had been affect- 
ed with it could live until twenty, forty, fifty, and 
even sixty years, without taking into the account the 
length of time their lives might have been prolonged 
if they had not fallen victims to other diseases. The 
palpitations, the intermittance and irregularity of the 
pulse, the bellows sound, and the purring tremor in 
the precordial region, supposing them really pro- 
duced by a communication between the right and 
left cavities of the heart, should not be considered 
as pathognomonic symptoms, for these symptoms are 
likewise met with in the contraction of the orifices. 
Besides, it is of no great consequence to know, pre- 
cisely, to what kind of disease of the heart the symp- 
toms noticed appertain; it is sufficient that they indu- 
bitably announce an obstruction to the circulation. 

M. Louis, in the memoir which he has published, 
thinks that the communication between the right 
and left cavities is always congenital. Perhaps this 
assertion is too general. In fact, we may readily con- 
ceive that an ulcer, which should occupy the auricu- 
lar or ventricular septum, might be converted into a 
perforation, in consequence of which the red and the 
black blood would mix in a variable proportion; we 
think, indeed, that such a case is presented in some 
of the patients whose history M. Louis has related. 

55 



434 DISEASES OF THE HEART. 

Finally, although the perforation of the foramen ovale 
is most frequently, without doubt, congenital, we 
think also that it may sometimes be accidental, and 
that violent exertions may burst the foramen, by de- 
taching the valvular laminae which close it, as some- 
times happens in a rupture of one of the columnar, or 
even the parietes of the heart: this is likewise the 
opinion of M. Laennec. 

Buffon, Bichat, and several others since, have 
imagined that certain amphibious animals possessed 
the faculty of remaining a long time under water, 
only because they had been affected with the mal- 
conformations of which we have been speaking. Cor- 
visart has, with reason, it appears to us, regarded this 
opinion as fabulous, if not entirely erroneous. In con- 
tradistinction to the perforated state of the foramen 
ovale after birth, we ought to say a word respecting 
its closure in the foetus: a defect of conformation 
which must be more fatal to the foetus than the pre- 
ceding is to the child which has seen the light, or 
even to the adult. Vieussens, in his Treatise on the 
Structure of* the Heart, (Chap. viii. p. 35,) relates 
the history of a child in whom this defective forma- 
tion was observed; a fact which appears to assimilate 
the circulation of the foetus with that of the adult, 
whilst that of which we have just before spoken 
approximates the circulation of the adult to that of 
the foetus. 

This will also be a proper place to speak of those 
transpositions of the cavities of the heart, which 
have been imagined by authors to explain in what 
manner hypertrophy, or, to make use of their expres- 
sion; active aneurism of the right ventricle is devc- 



DISEASES OF THE HEART. 435 

loped. But we would again observe, that such vices 
of conformation are facts at least very doubtful; since 
the physicians who admit them in order to make na- 
ture subservient to their method of explanation, can- 
not adduce any example of it in their own experi- 
ence. Besides, we have attempted to explain the 
mechanism, or rather the formation of hypertrophy 
of the right ventricle, without resorting to the inter- 
vention of such an hypothesis. 



ARTICLE II. 

OF THE DISPLACEMENTS OF THE HEART. 

The heart is susceptible of various changes of po- 
sition, which may produce a more or less sensible ob- 
struction of the freedom and regularity of its func- 
tions, although, in many cases, the displacement is 
not followed by any disturbing accident. The dis- 
placement of the heart may be either congenital or 
accidental; that is to say, the result of a disease, de- 
veloped after birth. Cases of the first kind have 
been related by authors. Buttner, Wilson, Shultz,* 
and Martinez,! have found the heart situated outside 
the cavity of the chest, or even in the right side of 
that cavity. Klinz J relates the history of a young 
man whose heart was placed perpendicularly in the 

* Acta Academ, Scientiarum Succiae, anni 1763, vol. xxiv. p. 27. 
f Halleri Disputat. Anatomies Sel, vol. ii. p. 510. 
± Ephem. Nat. Curios, vol. x. obs. 39. 



436 DISEASES OF THE HEART. 

pectoral cavity, and no trace of the left lung could 
be discovered. 

But let us pass on to those displacements of the 
heart which occur during life, in consequence of 
certain diseases. We may distinguish two species of 
them; one in which the organ has only changed its 
direction, and another in which it is removed out of 
its natural situation. We have already spoken of 
cases where the heart was situated transversly in the 
thoracic cavity,* and we have said that this defect 
of position is frequently to be observed where there 
is considerable hypertrophy and dilatation of the 
heart. Other observers have found the heart situ- 
ated perpendicularly, like that of quadrupeds. The 
examples of displacement of the heart are not very 
uncommon. Lancisi and Morgagni have spoken of 
them under the title of prolapsus of the heart, the 
only defective position mentioned in the work of Cor- 
visart. In the cases where this organ has considera- 
bly augmented in size, it rests with its whole weight 
on the diaphragm, produces a depression, and be- 
comes in part enveloped like a kind of pouch. A 
tumour w 7 hich should compress the heart from above 
downward, as observed by Morgagni in a case of 
aneurism of the aorta, would produce the same dis- 
placement. Some have thought that prolapsus of 
the heart might also be the effect of a relaxation of 
the vessels, to which it is, as it were, suspended. 

We observe an opposite defect in the situation of 
the heart, in those cases where a tumour of the ab- 
dominal viscera pushes the thoracic organs upward 

* See Plate It 



DISEASES OF THE HEART. 437 

toward the superior part of the cavity which con- 
tains them. 

Sennert found the heart of a student concealed in 
the right cavity of the thorax, coinciding with a dis- 
ease which had brought on a consumption of the left 
lung.* The various tumours of the pectoral cavity 
may, tike those of the abdomen, push the heart out 
of its natural position, and force it into the right side, 
as happened in the case related by Sennert. Among 
a great many authors who have observed this kind 
of transposition of the heart, we ought to mention M. 
Larrey. In the case reported by this celebrated sur- 
geon, the displacement of the heart, demonstrated by 
an inspection of the body, was produced in conse- 
quence of an encysted dropsy, or, perhaps, pleurisy 
with an effusion of the left pleura. During the life 
of the patient, the pulsations of the heart were felt 
under the right breast. Boerhaave,f at the opening 
of the body of the Marquis de St. Auban, found the 
heart thrown backward into the right cavity of the 
chest, in consequence of the compression produced 
by an enormous tumour situated in the left side of 
the thorax. These examples are sufficient to prove, 
undeniably, that the heart may be located in the right 
cavity of the chest. 

We ought to remark, that the malpositions point- 
ed out, have all been the result of some disease either 
of that organ, or of the pectoral or abdominal viscera; 
consequently, they ought to be considered as symp- 
toms of other diseases, and not as primitive and essen- 



* Practica, i. ii. p. 2 et 15. Lugd. Batav. 1650. 
f Zimmerman Traite de l'Expen. i. iii. ch. iv. 



438 DISEASES OF THE HEART. 

tial diseases; an important distinction in regard to 
the treatment. The history of these displacements 
includes that of all those diseases which may com- 
press the heart, and thereby give rise to this purely 
mechanical lesion. 

The diagnosis of the defective positions of the heart 
is by no means difficult, especially in the present 
day, when we are in possession of a mode of explo- 
ration, the remarkable advantages of which have 
been so frequently noticed. We may therefore re- 
cognise the disease by the change of place where the 
pulsations of the heart are either seen, heard or felt; 
but this knowledge is of very little importance : the 
diagnosis of the principal disease should be the spe- 
cial object of attention with the physician. The dan- 
gerous consequences of the displacement of the heart 
relate entirely to the disease of which it is only a 
symptom. Brera thinks that the compression of the 
heart from any cause, may give rise to the symptoms 
which constitute angina pectoris. Testa, in combat- 
ting this idea, was led to believe that the causes which 
compress the heart exercise a yet greater compres- 
sion on the lungs; so that we may, with the greatest 
reason refer angina pectoris to this compression of 
the lungs, — an opinion, however, which Testa did 
not propose. 



DISEASES OF THE HEART. 439 






SECTION VII. 

OF THE CONCRETION OF THE BLOOD, VULGARLY DE- 
NOMINATED POLYPI OF THE HEART AND LARGE VES- 
SELS. 

It would take up too much room in this place to 
relate every thing that has been said respecting po- 
lypi of the heart in the discussions of the two last 
centuries. Bartoletti and Rossini were the first to 
give this name to the concretions so frequently met 
with in the heart; a term founded on the resemblance 
which they supposed they had discovered between 
these concretions and certain polypi of the uterus 
and nasal fossse. Kerkring demonstrated that the for- 
mation of the concretions of the blood in the heart 
totally differed from those of polypi of the uterus and 
nasal fossse, by producing similar coagulations, almost 
instantly, by injecting sulphuric acid into the blood 
vessels of living dogs. The objection of Kerkring 
lost much of its value when the polypi of the heart 
were afterwards distinguished into the true and the 
false. The last are formed by the coagulum of the 
blood, while red or partly white; the first consist of 
whitish dense concretions of a cellular texture. The 
distinction of polypi into true and false continued to 
prevail in the schools until Morgagni and Senac sub- 
mitted this point of doctrine to rigorous criticism, 



440 DISEASES OF THE HEART. 

and even doubted the existence of real polypi. Lieu- 
taud, afterwards, formally denied it. Pasta, in a work 
in other respects very ingenious, sought to demon- 
strate that all those pretended polypi of the heart 
were only the result of a spontaneous coagulation of 
blood, supervening after death, or only a few mo- 
ments previously; and that all the histories of disease 
produced by the presence of such polypi have been 
considered in an erroneous point of view. Burse- 
rius afterwards revived the opinion of Malpighi, 
Manget, Pechlin, Peyer, F. Hoffmann, and J. B. 
Fantoni, in sustaining the opinion that polypi of the 
heart ought to be regarded as the causes of disease; 
and he maintained, at the same time, that they might 
be formed during life. This theory of polypi, how- 
ever, still remained doubtful, and as it were vascil- 
lating; for although many physicians entirely rejected 
it, it obtained the assent of others. Corvisart, Testa, 
Burns, Kreisig, and M. Laennec, have occupied 
themselves anew with this most important question; 
and all have agreed in this point, that polypi may be 
formed during life, and that they may become the 
source of certain symptoms, connected with the dis- 
orders of the heart, which, in truth, it is very diffi- 
cult to determine by sure and infallible signs. Far- 
thermore, it is incontestable in the present day, that 
polypous concretions may form in the heart and large 
vessels a long time before death. Facts are not want- 
ing to prove such an assertion : there is not, perhaps, 
a single vessel of considerable size in which the con- 
cretions in question have not been observed, and 
which are especially very common in the veins. The 
two venae cavae, the jugular veins, the vena porta 1 . 



DISEASES OF THE HEART. 441 

all the veins of the extremities, those of the lungs, 
the sinuses of the cranium, the carotid arteries, the 
arteries of the limbs, &c. : all these vessels have been 
found, in many cases, more or less completely obli- 
terated by the formation of sanguine concretions, of 
polypiform masses. We have found similar concre- 
tions in the heart itself, and particularly iti its right 
cavities.* 

§ I.— ANATOMICAL CHARACTERS OF POLYPOUS CONCRETIONS. 

Polypi of the heart and large vessels, formed after 
death, or in the last moments of life, are nothing more 
than common coagulated blood, which it is not ne- 
cessary to describe. The concretions of somewhat 
longer standing are, for the most part, deprived of 
their red colouring matter; they somewhat resemble 
fibrinous masses, or, more correctly, certain pseudo- 
membranous productions. If the concretions are 
formed a longer time before death, their consistence 
is firmer; they adhere to the parietes of the heart, 
and frequently are so entangled in the meshes of the 
ventricles that they are broken on drawing them out : 
their resemblance to fibrine or muscular flesh boiled 
and deprived of its colouring matter, is still more ap- 
parent; and they present, in some measure, the first 
rudiments of organization. Finally, we sometimes 
meet with these concretions in an organized state, 
as may be seen from the cases in the note below. f 

* See, in volumes ii. and v. of the Archives Generates de Medecine, the me- 
moir of M. J. Bouillaud, on obliteration of the veins, and passive dropsies. 

f A girl, eighteen years of age, had two enormous tumours on the right 
shoulder, and axilla of that size, for which she entered the Hotel Dieu, 26th 
of October, 1822. The superior right limb was swollen and infiltrated* 

56 



442 DISEASES OF THE HEART. 

We think that the organization of polypiform con- 
cretions takes place in the same manner as that of 
false membranes, and that this is particularly the case 
in those which are the result of a phlegmasia of the 
internal membrane of the heart, which, for that rea- 
son, Kreisig has called polypous carditis, by com- 
paring it to the angina of the same name. 

The globular vegetations of M. Laennec, apper- 
tain to the polypiform concretions in question; which 

The patient expectorated a large quantity of blood, which we perceived to 
have been furnished by one of the alveoli. The illustrious surgeon of that 
hospital employed the most rational means of removing- these symptoms. The 
patient, however, was totally incurable, and died of her disease the 13th of 
December following. — The right auricle of the heart was found filled, princi- 
pally, with a soft, almost gelatinous coagulum, containing in its centre vesicles 
filled with a semi-concrete fluid,f interspersed with an infinite number of in- 
jected red or black vessels. This polypiform concretion extended upwards into 
the vena cava superior, right subclavian and jugular veins, and was in some 
measure confounded with their parietes, which were strongly dilated; it was 
also prolonged into the right ventricle. — The superior extremities, and the 
face, were the only parts infiltrated, &c. 

(Case, communicated by M. Senn, and extracted from the Memoire sur 
rObliter. des Veines, as well as the following recorded by Dr. Thibert.) 

A commissioner, thirty-six years of age, entered the hospital of la Charite, 
in the month of March, 1817, and died with symptoms which authors, until 
the present moment, have attributed to an aneurism of the heart. The right 
cavities of the heart, besides blood recently clotted, contained portions of 
organized fibrino-albuminous matter, adhering to the parietes by filaments, 
which were unavoidably broken when removed, extending into the vena 
cava superior, and especially into the inferior, and obstructing almost com- 
pletely the orifice of the pulmonary artery, &c. 

Certainly, from the two interesting facts related in these few lines, we 
should be wonderfully incredulous, not to admit that polypiform concretions 
may be developed in the heart during life, and for a very long time before 
death. To these examples of the organization of sanguineous concretions, 
we may add the xxxvi. case of this work, which refers to a man who died of 
aneurism of the aorta. The lamellated coagulum, of which we have formerly 
given a long description, offered manifest traces of organization. 

t It is not uncommon to meet with a coagulum of red blood, having, on its exterior, a 
large white polypous mass of rather long standing. 



DISEASES OP THE HEART. 443 

also, perhaps, have an important influence in the pro* 
duction of certain vegetations of the valves. 



§ H.— FORMATION OF POLYPOUS CONCRETIONS. 

After an attentive examination of a great number 
of facts, we are convinced that inflammation of the 
vessels, and an interruption or considerable obstruc- 
tion to the course of the blood in their canal are, if 
not the only, at least the two principal causes, which 
induce the formation of polypiform coagulations. It 
would be rather difficult to tell in what manner in- 
flammation produces the concretion of blood in the 
heart, or in the vessels; how the same phenomenon 
occurs after a remission or an interruption of the cir- 
culation. This explanation is so much the more dif- 
ficult, as, in the actual state of physiology and che- 
mistry, we do not well know by what mechanism the 
coagulation of blood taken from the vessels is effected. 
Let us be content, therefore, for the present, with 
noticing facts, in expectation that physiology may 
some day furnish the theory. Moreover, it is evi- 
dent that all the causes capable of impeding or inter- 
cepting the course of the blood, such as ligatures of 
the vessels, their compression by tumours, &c, are 
calculated to produce the polypiform concretions 
which occupy us. Hence the reason why, at the ap- 
proach of death, when the circulation goes on only 
in a slow and almost imperceptible manner, these po- 
lypous masses which we almost constantly meet with 
in the heart and large vessels, begin to form, and es- 
pecially in the right side of the heart and the ves- 
sels which it receives or gives off. Hence the rea- 



444 DISEASES OF THE HEART. 

son why, if we practise blood-letting in a person who 
is about to die from the distress of a great obstruc- 
tion to the circulation, the blood drawn is black, 
thick, half coagulated, and flows with much difficulty. 
We have before seen that the coagulum with con- 
centric laminaj of certain aneurismal tumours are 
formed in the mode we have here explained; that is 
to say, by a subsidence of the circulation in the aneu- 
t rismal sac. 

§ m.—OF THE EFFECTS AND SYMPTOMS OF POLYPOUS CON^ 
CRETIONS IN GENERAL. 

Certain phenomena and diseases have been attri- 
buted for a long time to these concretions, which 
depend upon some other organic affection of the 
heart. This opinion, of their polypiform origin, 
which is perfectly erroneous, prevailed very much 
about the middle of the last century, and physicians 
had so popularized it, that polypi of the heart were 
spoken of in the world at that time, in the same 
manner as aneurism is at the present day, and per- 
haps with as little precision. Who does not know 
that the celebrated Jean J. Rousseau journeyed all 
(the way on foot to Montpellier, to seek advice for a 
polypus of the heart, which he certainly could not 
have done, had the illustrious melancholic really been 
affected with a disease the idea of which so seriously 
disturbed his ardent imagination. 

The evident effects of polypiform concretions are 
to induce more or less obstruction of the circula- 
tion. Those which form in the last moments of 
life, in many diseases, and especially in those of the 
heart, considerably increase the obstruction to the 



DISEASES OF THE HEART. 445 

course of the blood, aggravate all the symptoms, and 
even determine syncopes, or death itself, when they 
obliterate, more or less completely, the cavities or 
orifices of the heart. M. Laennec thinks we may 
recognise these polypi of the heart when rather large 
by the following symptoms: — " When the pulsations 
of the heart which had all along been regular, sud- 
denly become so abnormal, obscure, and confused, 
that we can no longer analyze them, we might sus- 
pect the formation of a polypiform concretion: if 
this difficulty occurs only on one side, the thing is 
almost certain."* 

We should add that it is, perhaps, to the momen- 
tary presence of a polypous concretion in some one 
of the cavities of the heart, or their orifices, that we 
must attribute the bellows sound observed in some 
individuals, only at intervals. This kind of inter- 
mission of the symptoms we have noticed, announces 
a moveable and temporary obstacle, and prevents us 
from confounding it with the continuous tremor 
which accompanies the permanent contractions of 
the orifices. 

Concretions of blood of very long standing, and 
even when organized, constitute permanent obstruc- 
tions of the circulation, and produce different effects 
according as they occupy the heart and large ves- 
sels, or the vessels of moderate size. In the first 
case their effects are absolutely the same as those of 
which we have fully spoken in the chapter on the 
contractions of the orifices of the heart; that is to say, 
considerable dyspnoea, the most intolerable anxiety 

* Auscult. Med., torn. ii. page 333, 



446 DISEASES OF THE HEART. 

and general infiltration :* in the second case, that is to 
say, when vessels of a moderate size are rendered im- 
permeable by the presence of a fibrinous concretion, 
things proceed somewhat differently, accordingly as 
these vessels are arterial or venous. When they are 
arteries, as happens, for example, after a ligature 
which we are under the necessity of applying in cer- 
tain diseases, the circulation is re-established by 
means of the collateral arteries, which dilate in a 
very remarkable manner, and soon there does not 
remain any symptom which would lead us to suspect 
an obliteration of the arterial trunk;f but if the ves- 
sels obliterated by fibrinous coagula appertain to the 
venous system, which is by far the most frequent, 
those are the phenomena which we observe. It hap- 
pens sometimes that the course of the venous blood is 
established by means of a collateral circulation, as we 
have seen to have taken place in the case where a 
principal artery has been obliterated. In all cases 
nature is less ready, if we may be permitted to say 
so, to establish the current of the venous than that of 

* It may happen, however, that dropsy is not general. Thus when the 
concretion occupies one of the venae cavae only, we sometimes observe an 
isolated infiltration of the super.or parts, and sometimes a similar affection 
of the inferior parts, according 1 as the obstacle is seated in the vena cava su- 
perior or inferior. 

f Nevertheless, in some unfortunate cases, the collateral circulation either 
is not established, or becomes incapable of preserving* heat and life in the ex- 
tremities, where the principal artery is unfitted to convey the blood. Para- 
lysis and gangrene of the extremities, are the deplorable accidents which 
this defect of arterial circulation induces. M. Rostan relates two interesting 
cases of paralysis of the extremities, produced by an obliteration of the prin- 
cipal artery, in his work on the softening of the brain. This paralysis and 
gangrene ought then to be ranked among the number of effects, and, conse- 
quently, symptoms which might lead us to suspect if not to recognise obli- 
teration of the arteries. 



DISEASES OF THE HEART. 447 

the arterial blood. Also, most commonly, when the 
principal veins are obliterated, we observe an infil- 
tration of the parts from whence these vessels bring 
the blood and serum. These partial dropsies denote 
an obstructed state of the circulation of the veins; 
and we may affirm that of all the causes capable of 
producing these passive dropsies, the most common 
is that which has been here noticed. This theory, 
founded on the most repeated observation, agrees in 
other respects admirably well with the physiological 
experiments which relate to the functions of the ve- 
nous system.* 



* Consult, for more ample details, the memoir on Obliteration of the Veins, 
inserted in the Archives Generates de Medecine, 



448 DISEASES OF THE HEART. 



SECTION vm. 

OF THE RECIPROCAL COMPLICATION OF THE 
VARIOUS DISEASES OF THE HEART. 

Nothing' is more uncommon, as we have already 
said, than to meet with cases where the heart is the 
seat of one affection only. On the contrary, the va- 
rious lesions which we have studied individually, and 
in a manner somewhat abstract, are united together, 
two and two, three and three, &c, and form thou- 
sands of combinations. We meet with disease of the 
muscular substance, of the membranous substances of 
the organ, and of its vascular system at the same 
time; the same texture is sometimes the seat of differ- 
ent affections: thus we meet with the muscular pari- 
etes simultaneously dilated and hypertrophied, soft- 
ened and hardened, and sometimes we meet with 
these four or even more diseases united. Contraction 
of the orifices is almost constantly complicated with 
dilatation and hypertrophy, of which it is one of the 
most frequent causes, &c. &c. It will be readily 
perceived that it is impossible for us to give any ex- 
amples of these innumerable complications, or even 
to point them out. It is sufficient for us to observe 
that almost all the observations contained in this work 
are examples of it. 

It is this complication of the diseases of the heart, 



DISEASES OF THE HEART. 449 

so common, and we might say inevitable, which has 
been the source of so many of the errors we have had 
occasion to notice in various parts of this work. It 
increases undoubtedly the difficulty of diagnosis; be- 
cause frequently the existence of a given disease of 
the heart is in opposition to the manifestation of many 
of the symptoms of some other disease of that organ. 
Nevertheless we may be assured that with attention, 
and by recurring to all the modes of exploration 
which art possesses in the present day, an experienced 
physician will be able, in the great majority of cases, 
to recognise the principal lesion, and that very fre- 
quently, even, he may be able to ascertain with admi- 
rable facility the most inconsiderable affections, the 
diagnosis of which, to say the least, were very uncer- 
tain before the discovery of auscultation. 



57 



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though the precise extent of the work cannot be fixed 
with certainty, yet there is a limit which will not be 
exceeded ; and the subscribers may look forward to 
the possession, within a reasonable time, of a complete 
library of instruction, amusement, and general refer- 
ence, in the regular form of a popular Cyclopaedia. 

The several classes of the work are — 1, NATURAL 
PHILOSOPHY; 2, The USEFUL and FINE ARTS; 
3, NATURAL HISTORY; 4, GEOGRAPHY; 5, 
POLITICS and MORALS; 6, GENERAL LITE- 
RATURE and CRITICISM; 7, HISTORY; 8, BI- 
OGRAPHY. 

In the above abstruse and technical departments 
of knowledge, an attempt has been made to convey 
to the reader a general acquaintance with these sub- 
jects, by the use of plain and familiar language, ap- 
propriate and well-executed engravings, and copious 
examples and illustrations, taken from objects and 
events with which every one is acquainted. 

The proprietors formerly pledged themselves that 
no exertion should be spared to obtain the support of 
the most distinguished talent of the age. They trust 
that they have redeemed that pledge. Among the 
volumes already published in the literary department, 
no less than four have been the production of men 
who stand in the first rank of literary talent, — Sir 
James Mackintosh and Sir Walter Scott. In the sci- 
entific department, a work has been produced from 
the pen of Mr. Herschel, which has been pronounced 
by the highest living authority on subjects of general 
philosophy, to contain " the noblest observations on 
the value of knowledge which have been made since 
Bacon," and to be " the finest work of philosophical 
genius which this age has seen." 



The following is a selection from the list of Contributors, 

The Right Honorable Sir JAMES MACKIN- 
TOSH, M. P. 

The Right Rev. The Lord Bishop of Cloyne. 

Sir WALTER SCOTT, Bart. 

JOHN FREDERICK WILLIAM HERSCHEL, 
Esq. 

THOMAS MOORE, Esq. 

J. B. BIOT, Member of the French Institute, 

ROBERT SOUTHEY, Esq. Poet Laureate. 

The Baron CHARLES DUPIN, Member of the 
Royal Institute and Chamber of Deputies. 

THOMAS CAMPBELL, Esq. 

T. B. MACAULEY, Esq. M. P. 

DAVID BREWSTER, LL.D. 

J. C. L. SISMONDI, of Geneva. 

Capt. HENRY KATER, Vice President of the 
Roval Society. 

The ASTRONOMER ROYAL. 

DA VIES GILBERT, Esq. M. P. 

S. T. COLERIDGE, Esq. 

JAMES MONTGOMERY, Esq. 

The Right Hon. T. P. COURTENAY, M.P. 

J. J. BERZELIUS, of Stockholm, F. R. S., &c. 

The. Rev. G. R. GLEIG. 

T. PHILLIPS, Esq. Prof, of Painting, R. A. 

Rev. C. THIRLWALL, Fellow of Trinity College, 
Cambridge. 

ANDREW URE, M. D. F. R. S., &c. &c. &c. 



SB. LAEDNEE'S 

CABINET CTClOPiEDIA. 



VOLUMES PUBLISHED. 

I. II— HISTORY of SCOTLAND. By Sir Walter 
Scott. 

III. VI— HISTORY of ENGLAND. By Sir James 
Mackintosh. In 8 Vols. Vols. I. and II. 

IV— OUTLINES of HISTORY. 

V— HISTORY of the NETHERLANDS. By T. C. 
G rattan, Esq. 

VII. VIII. XII— HISTORY of FRANCE. By Eyre 
Evans Crowe. In 3 Vols. 

IX— MECHANICS. By Capt. Kater and Dr. 
Lardner. 

X— A PRELIMINARY DISCOURSE on the OB- 
JECTS, ADVANTAGES, and PLEASURES of 
the STUDY of NATURAL PHILOSOPHY. In 
1 Vol. Bv J. F. W. Herschel, Esq. 

XI— BIOGRAPHY of EMINENT BRITISH 
STATESMEN. 

XIII— HYDROSTATICS and PNEUMATICS. By 
Dr. Lardner. 

XIV— HISTORY of the PROGRESS and PRE- 
SENT SITUATION of the SILK MANUFAC- 
TURE. 

XV— HISTORY of the ITALIAN REPUBLICS. 
By J. C. L. Sismondi. 

XVI— HISTORY of the PROGRESS and PRE- 
SENT STATE of the MANUFACTURE of 
PORCELAIN and GLASS. 

XVII. XVIII. XX. XXI. XXII— HISTORY of SPAIN 
and PORTUGAL. 5 vols. 

XIX— HISTORY of SWITZERLAND. 

XXIII— HISTORY of ENGLAND. By Sir James 
Mackintosh. Vol. III. 



Volumes in immediate preparation* 

The HISTORY of the WESTERN WORLD. In 
4 Vols. Vol. I. The UNITED STATES of AMER- 
ICA. 

Two volumes of this work, nearly ready, will 
complete the History of the United States to the 
present time. The two remaining volumes will 
be devoted to South America and the West India 
Islands. 

A HISTORY of IRELAND, to the UNION. In 2 
Vols. By T. Moore, Esq. 

A PRELIMINARY DISCOURSE on the USEFUL 
ARTS and MANUFACTURES. By the Baron 
Charles DufiN, Member of the Institute of France 
and of the Chamber of Deputies. 

A HISTORY of the MOORS. In 3 Vols. By Rob- 
ert Southey, Esq. 

LIVES of the MOST EMINENT LITERARY 
MEN of ALL NATIONS. In 8 Vols. By Scott, 
Southey, Moore, Mackintosh, Montgomery, 
Cunningham, and all the principal Literary and 
Scientific Contributors to the Cyclopaedia. 

A TREATISE on ASTRONOMY. By J. F. W. 
Herschel, Esq. 

GEOGRAPHY. In 4 Vols. By W. Cooley, Esq. 
author of the " History of Maritime Discovery." 

LIVES of the MOST DISTINGUISHED BRITISH 
NAVAL COMMANDERS. By R. Southey, Esq. 

LIVES of the MOST DISTINGUISHED BRITISH 
MILITARY COMMANDERS. By the Rev. G. R. 

A TREATISE on OPTICS. By David Brew- 
ster. 

The HISTORY" of GREECE. In 3 Vols. By the 
Rev. C. Thirl wall, 

LIVES of EMINENT BRITISH ARTISTS. By 
VV. Y. Otley, Esq. and T. Phillips, R. A. Professor 
of Painting to the Royal Academy. 

A TREATISE on ELECTRICITY and MAGNET- 
ISM. By M. Biot, Member of the French Insti- 
tute. 



41 BOOKS THAT YOU MAY CARRY TO THE FIRE, AND HOLD 
READILY IN YOUR HAND, ARE THE MOST USEFUL AFTER 
ALL. A MAN WILL OFTEN LOOK AT THEM, AND BE 
TEMPTED TO GO ON, WHEN HE WOULD HAVE BEEN 
FRIGHTENED AT BOOKS OF A LARGER SIZE, AND OF A 
MORE ERUDITE APPEARANCE. 1 ' — Dr. Johnson. 

"We advisedly call the Cabinet Cyclopedia a great 
undertaking, because we consider, that in its effects on 
the tone and habits of thought of what is known by the 
phrase, ' the reading public,' it will be, if carried through 
in the spirit of its projection and commencement, one of 
the most invaluable productions of modern literature. * * 

" But these advantages, eminent as they undoubtedly 
are, are not the sole nor the chief recommendations of 
the Cabinet Cyclopaedia. Neither is it on the extreme 
cheapness of the publication, nor the federal independence 
— if we may so speak — of its several volumes, that we 
rest our prediction of its influence on the tone of think- 
ing of the present, and on the literature of the next gen- 
eration — but on the promise, amounting almost to a moral 
certainty, of the great excellence of its execution. A mul- 
titude of persons eminent in literature and science in the 
United Kingdom are employed in this undertaking; and, 
indeed, no others should be employed in it ; for it is a truth 
that the profound ;uid practised writer alone is capable of 
furnishing a l popular compendium.' 

" What parent or guardian that throws his eye over the 
list of its contributors bat must be rejoiced by meeting 
the names of those who are in themselves a guarantee 
of intellectual and moral excellence?"— Literary Gazette. 

" The plan of the work appears well adapted to the pur- 
pose it is proposed to fulfil— that of supplying a series of 
publications, embracing the whole range of literature 
and science, in a popular and portable form ; while the 
excellence of the execution is guarantied by the judgment 
displayed in the selection of writers. The list of authors 
employed in this ambitious undertaking comprises some 
of the most eminent men of the present age." — Atlas. 

" The Cyclopaedia, when complete, will farm a valuable 
work of reference, as well as a most entertaining and in- 
structive library. It is an essential principle in every part 
of it, that it should bii clear and easily understood, and 
that an attempt should everywhere be made to unite 
accurate information with an agreeable manner of con- 
veying it. It is an experiment to try how much science 
may be taught with little crabbed or technical language, 
and how far the philosophical and poetical qualities of 
history may be preserved in its more condensed state. It 
possesses also the most indispensable of all the qualities 
of a work intended for general instruction— that of cheap- 
ness. Whatever the plan might be, it was evident that 
the grand difficulty of Dr. Lardner was to unite a body 
of writers in its execution, whose character or works af- 
forded the most probable hope that they were fitted for a 
task of which the peculiarity, the novelty, and even the 
prevalent relish for such writings greatly enhance the dif- 
ficulty. We do not believe, that in the list of contribu- 
tors, there is one name of which the enlightened part of 
the public would desire the exclusion. 

" In science, the list is not less promising. The namps 
of the President, Vice-Presidents, and most distinguished 
Fellows of the Royal Society, are contained in it. A 
treatise on astronomy, by Herschel ; on optics, by Brews- 
ter; and on mechanics, by Lardner; need be only recom- 
mended by the subjects and the writers. An eminent 
Prelate, of the first rank in science, has undertaken a 
noble subject which happily combines philosophy with 
religion. Twelve of the most distinguished naturalists 
of the age, Fellows of the Linnaean and Zoological So- 
cieties, are preparing a course of natural history. Others 
not less eminent in literature and science, whose names it 
is not needful yet to mention, have shown symptoms of an 
ambition to take a place among such fellow-laborers."— 
Times. 

"The topics, as may be supposed, are both judiciously 
selected and treated with ability. To general readers, 
and as part of a family library, the volumes already pub- 
lished possess greet recommendations. For the external 
beauties of good printing and paper they merit equal com- 
mendation."— Bait. American. 

"The uniform neatness of these volumes, their very 
moderate price, and the quantity of information which 
they contain, drawn from the best and most attractive 
sources, have given them deserved celebrity, and no one 
who desires to possess such information, should hesitate 
a moment to add them to his library."— Fed. Oaiette. 

" This excellent work continues to increase in public 
favor, and to receive fresh accessions of force to its corps 
of contributors. — Lit. Gazette. 



LARDNERS CABINET CYCLOPAEDIA. 



'OF THE MANY WORKS WHICH HAVE BEEN LATELY PUB- 
LISHED IN IMITATION, OR ON THE PLAN ADOPTED BY THE 
SOCIETY FOR THE DIFFUSION OF USEFUL KNOWLEDGE, DR. 
LARDNER'S CYCLOPEDIA IS BY MUCH THE MOST VALUA- 
BLE, AND THE MOST RECOMMENDED BY DISTINGUISHED 
ASSISTANCE, SCIENTIFIC AND LITERARY." 

Edinburgh Review. 



HISTORY OP ENGLAND. By Sir James 
Mackintosh. In 8 Vols* III Vols* pub- 
lished* 

" In the first volume of Sir James Mackintosh's His- 
tory of England, we find enough to warrant the antici- 
pations of the public, that a calm and luminous philoso- 
phy will diffuse itself over the long narrative of our Brit- 
ish History."— Edinburgh Review. 

" In this volume Sir James Mackintosh fully developes 
those great powers, for the possession of which the public 
have long given him credit. The result is the ablest com- 
mentary that has yet appeared in our language upon some 
of the most important circumstances of English History." 
— Atlas. 

" Worthy in the method, style, and reflections, of the 
author's high reputation. We were particularly pleased 
with his high vein of philosophical sentiment, and his 
occasional survey of contemporary annals." — National 
Gazette. 

" If talents of the highest order, long experience in po- 
litics, and years of application to the study of history 
and the collection of information, can command superi- 
ority in a historian, Sir James Mackintosh may, without 
reading this work, be said to have produced the best his- 
tory of this country. A perusal of the work will prove 
that those who anticipated a superior production, have 
not reckoned in vain on the high qualifications of the 
author."— Courier. 

" Our anticipations of this volume were certainly very 
highly raised, and unlike such anticipations in general, 
they have not been disappointed. A philosophical spirit, 
a nervous style, and a full knowledge of the subject, ac- 
quired by considerable research into the works of pre- 
ceding chroniclers and historians, eminently distinguish 
this popular abridgment, and cannot fail to recommend it 
to universal approbation. In continuing his work as he 
has begun, Sir James Mackintosh will confer a great bene- 
fit on his country."— Lond. Lit. Oazette. 

I Of its general merits, and its permanent value, it is 
impossible to speak, without the highest commendation, 
and after a careful and attentive perusal of the two vol- 
umes which have been published, we are enabled to de- 
clare that, so far, Sir James Mackintosh has performed 
the duty to which he was assigned, with all the ability 
that was to b9 expected from his great previous attain- 
ments, his laborious industry in investigation, his excel- 
lent judgment, his superior talents, and his honorable 
principles "—Inquirer. 

II We shall probably extract the whole of his view of 
the reformation, merely to show how that important topic 
has been handled by so able and philosophical a writer, 
professing Protestantism. — National Oazette. 

" The talents of Sir James Mackintosh are so justly and 
deeply respected, that a strong interest is necessarily ex- 
cited with regard to any work which such a distinguished 
writer mav think fit to undertake. In the present instance, 
as in all others, our expectations are fully gratified."— 
Gentleman's Magazine. 

" The second volume of the History of Engrand, form- 
ing the sixth of Carey & Lea's Cabinet Cyclopaedia, has 
been sent abroad, and entirely sustains the reputation of 
its predecessors. The various factions and dissensions, 
the important trials and battles, which render this period 
so conspicuous in the page of history, are all related with 
great clearness and masterly power."— Boston Traveller. 



BIOGRAPHY OF BRITISH STATESMEN: 
containing the Lives of Sir Thomas More, 
Cardinal Wolsey, Archbishop Cranmer, 
and Lord Burleigh* 

" A very delightful volume, and on a subject likely to 
increase in interest as it proceeds. * * * We cordially 
commend the work both for its design and execution."— 
L*nd. Lit. Gazette. 



HISTORY OF SCOTLAND. By Sir Walter 
Scott* In 2 Vols* 

" The History of Scotland, by Sir Walter Scott, we do 
not hesitate to declare, will be, if possible, more exten- 
sively read, than the most popular work of fiction, by the 
same prolific author, and for this obvious reason : it com- 
bines much of the brilliant coloring of the Ivanhoe pic- 
tures of by -gone manners, and all the graceful facility of 
style and picturesqueness of description of his other 
charming romances, with a minute fidelity to the facts 
of history, and a searching scrutiny into their authenti- 
city and relative value, which might put to the blush 
Mr. Hume and other professed historians. Such is the 
magic charm of Sir Walter Scott's pen, it has only to 
touch the simplest incident of every-day life, and it starts 
up invested with all the interest of a scene of romance ; 
and yet such is his fidelity to the text of nature, that the 
knights, and serfs, and collared fools with whom his in- 
ventive genius has peopled so many volumes, are regarded 
by us as not mere creations of fancy, but as real flesh and 
blood existences, with all the virtues, feelings and errors 
of common -place humanity." — Lit. Gazette. 



HISTORY OF FRANCE* By Eyre Evans 
Crowe* In 3 vols* 

HISTORY OF FRANCE, from the Restora- 
tion of the Bourbons, to the Revolution 
of 1830. By T. B* Macaulay, Esq. M* P. 
Nearly ready* 

" The style is concise and clear ; and events are sum- 
med up with much vigor and originality." — Lit. Gazette. 

" His history of France is worthy to figure with the 
works of his associates, the best of their day, Scott and 
Mackintosh."— Monthly Mag. 

" For such a task Mr. Crowe is eminently qualified. 
At a glance, as it were, his eye takes in the theatre of 
centuries. His style is neat, clear, and pithy; and his 
power of condensation enables him to say much, and 
effectively, in a few words, to present a distinct and 
perfect picture in a narrowly circumscribed space." — La 
Belle Assemblee. 

" The stvle is neat and condensed ; the thoughts and 
conclusions sound and just. The necessary conciseness 
of the narrative is unaccompanied by any baldness; on 
the contrary, it is spirited and engaging."— Bait. Ameri- 
can. 

"To compress the history of a great nation, during a 
period of thirteen hundred years, into three volumes, and 
to preserve sufficient distinctness as well as interest in 
the narrative, to enable and induce the reader to possess 
himself clearly of all the leading incidents, is a task by 
no means easily executed. It has, nevertheless, been well 
accomplished in this instance."— JV. Y. American. 

"Written with spirit and taste."— U. S. Gazette. 

"Could we but persuade our young friends to give 
these volumes a careful perusal, we should feel assured 
of their grateful acknowledgments of profit and pleas- 
ure."— JV. Y. Mirror. 

" At once concise and entertaining."— Saturday Bul- 
letin. 



THE HISTORY OF THE NETHERLANDS, 
to the Battle of Waterloo. By T. C. Grat- 
tan. 

" It is but justice to Mr. Grattan to say that he has 
executed his laborious task with much industry and pro- 
portionate effect. Undisfigured by pompous nothingness, 
and without anv of the affectation of philosophical pro- 
funditv, his style is simple, light, and fresh— perspicuous, 
smooth, and harmonious."— La Belle Assemblee. 

"Never did work appear at a more fortunate period. 
The volume before us is a compressed but clear and im- 
partial narrative."— Lit. Gaz. 

" A long residence in the country, and a ready access to 

libraries and archives, have furnished Mr. Grattan with 

materials which he has arranged with skill, and out of 

which he has produced a most interesting volume."— 

| Gent. Mag. 



CABINET LIBRARY. 



No. 1.— NARRATIVE OF THE LATE 
WAR IN GERMANY AND FRANCE. 
By the Marquess of Londonderry. With 
a Map. 

No. 2.— JOURNAL of a NATURALIST, 
with plates. 

No. 3.— AUTOBIOGRAPHY of SIR WAL- 
TER SCOTT. With a portrait. 

No. 4.— MEMOIRS of SIR WALTER RA- 
LEGH. By Mrs. A. T. Thomson. With a 
portrait 

No. 5.— LIFE of BELISARIUS. By Lord 
Mahon. 

No. 6.— MILITARY MEMOIRS of the 
DUKE of WELLINGTON. By Capt. 
Moyle Sherer. With a portrait. 

No. 7.— LETTERS to a YOUNG NATU- 
RALrST on the STUDY of NATURE 
and NATURAL THEOLOGY. By J. L. 
Drummond, M. D. With numerous en- 
gravings. 

IN PREPARATION. 

LIFE of PETRARCH. By Thomas Moore. 
CLEANINGS in NATURAL HISTORY, 

beinGf a Companion to the Journal of a Nat- 
uralist. 

" The Cabinet Library bids fair to be a series of great 
value, and is recommended to public and private libraries, 
to professional men, and miscellaneous readers generally. 
It is beautifully printed, and furnished at a price which 
will place it within the reach of all classes of society."— 
American Traveller. 

" The series of instructive, and, in their original form, 
expensive works, which these enterprising publishers are 
now issuing under the title of the "Cabinet Library," 
is a fountain of useful, and almost universal knowledge ; 
the advantages of which, in forming the opinions, tastes' 
and manners of that portion of society, to which this 
varied information is yet new, cannot be too highly 
estimated." — National Journal. 

'■ Messrs. Carey and Lea have commenced a series of 
publications under the above title, which are to appear 
monthly, and which seem likely, from the specimen before 
us, to acquire a high degree of popularity, and to afford 
a mass of various information and rich entertainment, 
at once eminently useful and strongly attractive. The 
mechanical execution is fine, the paper and typography 
excellent." — Nashville Banner. 



MEMOIRS OF THE lilFE OF SIR WAL- 
TER RALEGH, with some Account of the 
Period in which he lived. J&y MRS* A. T. 
THOMSON. With a Portrait. 

"Such is the outline of a life, which, in Mrs. Thom- 
son's hands, is a mine of interest ; from the first page to 
the last the attention is roused and sustained, and while 
we approve the manner, we still more applaud the spirit 
in which it is executed."— Literary Gazette. 



JOURNAL OF A NATURALIST. With 
Plates. 



and more particularly of our country readers. It will 
induce tbem, we are sure, to examine more closely than 
they have been accustomed to do, into the objects of ani- 
mated nature, and such examination will prove one of 
the most innocent, and the most satisfactory sources of 
gratification and amusement. It is a book that ought 
to find its way into every rural drawing-room in the 
kingdom, and one that may safely be placed in every 
lady's boudoir, be her rank and station in life what they 
may/' — Quarterly Review, No. LXXVIII. 

1 We think that there are few readers who will not 
be delighted (we are certain all will be instructed) by the 
Journal of a Naturalist.' "—Monthly Review. 

" This is a most delightful book on the most delightful 
of all studies. We are acquainted with no previous 
work which bears any resemblance to this, except 
White's History of Selborne,' the most fascinating piece 
of rural writing and sound English philosophy that ever 
issued from the press." — Athenaeum. 

1 The author of the volume now before us, has pro- 
duced one of the most charming volumes we remember 
to have seen for a long time." — New Monthly Magazine, 
June, 1829. 

1 A delightful volume— perhaps the most so— nor les3 
instructive and amusing— given to Natural History 
since White's Selborne."— Blackwood's Magazine. 

1 The Journal of a Naturalist, being the second num 
ber of Carey and Lea's beautiful edition of the Cabinet 
Library, is the best treatise on subjects connected with 
this train of thought, that we have for a long time pe- 
rused, and we are not at all surprised that it should have 
received so high and flattering encomiums from the Eng 
lish press generally." — Boston Traveller. 

"Furnishing an interesting and familiar account of 
the various objects of animated nature, but calculated 
to afford both instruction and entertainment."— Nash 
villc Banner. 

" One of the most agreeable works of its kind in the 
language." — Courier de la Louisiane. 

"It abounds with numerous and curious facts, pleas 
ing illustrations of the secret operations and economy of 
nature, and satisfactory displays of the power, wisdom 
and goodness, of the great Creator."— Philad. Album. 



-Plants, trees, and stones we note ; 



Birds, insects, beasts, and rural things. 

" We again most strongly recommend this little unpre- 
tending volume to the attention of every lover of nature, 



THE MARCHESS OF LONDONDERRY'S 
NARRATIVE OF THE LATE WAR IN 
GERMANY AND FRANCE. With a Map. 

" No history of the events to which it relates can be 
correct without reference to its statements."— Literary 
Gazette. 

"The events detailed in this volume cannot fail to 
excite an intense interest." — Dublin Literary Gazette. 

"The only connected and well authenticated account 
we nave of the spirit-stirring scenes which preceded the 
fall of Napoleon. It introduces us into the cabinets and 
presence of the allied monarchs. We observe the secret 
policy of each individual : we see the course pursued by 
the wily Bernadotte, the temporizing Metternich, and 
the ambitious Alexander. The work deserves a place in 
every historical library."— Globe. 

" We hail with pleasure the appearance of the first 
volume of the Cabinet Library." " The author had sin 
gular facilities for obtaining the materials of his work 
and he has introduced us to the movements and measures 
of cabinets which have hitherto been hidden from the 
world." — American Traveller. 

"It may be regarded as the most authentic of all the 
publications which profess to detail the events of the 
important campaigns, terminating with that which se- 
cured the capture of the French metropolis."— Nat. Jour- 
nal. 

" It is in fact the only authentic account of the memo- 
rable events to which it refers."— Nashville Banner. 

" The work deserves a place in every library."— Phila- 
delphia Album. 



LARDNER'S 
CABINET CYCLOPEDIA. 



' It is not east to devise a cure for scch a state 
of things (the declining taste for science;) but 
the most obvious remedy is to provide the edu- 
cated classes with a series of works on popular 
and practical science, freed from mathematical 
symbols and technical terms, written in simple 
and perspicuous language, and illustrated by facts 
and experiments, which are level to the capacity 
OF ordinary minds."— Quarterly Review. 



PRELIMINARY DISCOURSE ON THE OB- 
JECTS, ADVANTAGES, AND PLEAS- 
URES OF THE STUDY OF NATURAL 
PHILOSOPHY. By J. T. \V. Herschel, 
A. M« late Fellow of St« John's College, 
Cambridge. 

u Without disparaging any other of the many interest- 
ing and instructive volumes issued in the form of cabinet 
and family libraries, it is, perhaps, not too much to place 
at the head of the list, for extent and variety of condensed 
information, Mr. Herchers discourse of Natural Philoso- 
phy in Dr. Lardner's Cyclopaedia."— Christian Observer. 

" The finest work of philosophical genius which this 
age has seen."— Mackintosh's England. 

u By far the most delightful book to which the existing 
competition between literary rivals of great talent and 
enterprise has given rise."— Monthly Review. 

4i Mr. Herschel's delightful volume. * * * We find 
scattered through the work instances of vivid and happy 
illustration, where the fancy is usefully called into action, 
so as sometimes to remind us of the splendid pictures 
which crowd upon us in the style of Bacon."— Quarterly 
Review. 

" It is the most exciting volume of the kind we ever 
met with." — Monthly Magazine. 

u One of the most instructive and delightful books we 
have ever perused."— U. S. Journal. 



A TREATISE ON MECHANICS. By Capt. 
Kater, and the Rev* Dionysius Lardner. 
With numerous engravings* 

" A work which contains an uncommon amount of 
useful information, exhibited in a plain and very intelli- 
gible form."— Olmsted's Nat. Philosophy. 

"This volume has been lately published in England, as 
a part of Dr. Lardner's Cabinet Cyclopaedia, and has re- 
ceived the unsolicited approbation of the most eminent 
men of science, and the most discriminating journals and 
reviews, in the British metropolis. — It is written in a 
popular and in.elligible style, entirely free from mathe- 
matical symbols, and disencumbered as far as possible of 
technical phrases."— Boston Traveller. 

■ Admirable in development and clear in principles, and 
especially felicitous in illustration from familiar sub- 
jects." — Monthly Mag. 

" Though replete with philosophical information of the 
highest order in mechanics, adapted to ordinary capaci- 
ties in a way to render it at once intelligible and popu- 
lar."— Lit. Gazette. 

" A work of great merit, full of valuable information, 
not only to the practical mechanic, but to the man of sci- 
ence."— JV. Y. Courier and Enquirer. 



A TREATISE ON HYDROSTATICS AND 
PNEUMATICS. By the Rev. D. Lardner* 
With numerous engravings. 

" It fully sustains the favorable opinion we have already 
expressed "as to this valuable compendium of modern sci- 
ence."— Lit. Gazette. 

" Dr. Lardner has made a good use of his acquaintance 
with the familiar facts which illustrate the principles of 
science." — Monthly Magazine. 

" It is written with a full knowledge of the subject, 
and in a popular style, abounding in practical illustra- 
tions of the abstruse operations of these imporant sci- 
ences." — U. S. Journal. 



LARDNER'S 

CABINET CYCLOPEDIA. 



HISTORY of the RISE, PROGRESS, 
and PRESENT STATE of the SILK 
MANUFACTURE; with numerous En- 
gravings. 

" It contains abundant information in every depart- 
ment of this interesting branch of human industry — in 
the history, culture, and manufacture of silk."— Monthly 
Magazine. 

1 There is a great deal of curious information in this 
little volume."— Literary Gazette. 

HISTORY of the ITALIAN REPUBLICS; 

being a View of the Rise, Progress, and 
Fall of Italian Freedom. By J. C. L. De 

SlSMONDI. 

M The excellencies, defects, and fortunes of the gov- 
ernments of the Italian commonwealths, form a body 
of the most valuable materials for political philosophy. 
It is time that they should be accessible to the American 
people, as they are about to be rendered in Sismondi's 
masterly abridgment. He has done for his large work 
what Irving accomplished so well for his Life of Colum 
bus." — National Gazette. 



HISTORY of the RISE, PROGRESS, and 
PRESENT STATE of the MANUFAC- 
TURES of PORCELAIN and GLASS, 

With numerous Wood Cuts. 

" In the design and execution of the work, the author 
has displayed considerable judgment and skill, and has 
so disposed of his valuable materials as to render the 
book attractive and instructive to the general class of 
readers."— Sat. Ev. Post. 

" The author has, by a popular treatment, made it one 
of the most interesting books that has been issued of 
this series. There are, we believe, few of the useful 
arts less generally understood than those of porcelain 
and glass making." These are completely illustrated by 
Dr. Lardner, and the various processes of forming differ 
ently fashioned utensils, are fully described." 

HISTORY of the RISE, PROGRESS, and 
PRESENT STATE of the IRON and 
STEEL MANUFACTURE. (In press.) 

"This volume appears to contain all useful informa 
tion on the subject of which it treats."— Lit. Gazette. 



The HISTORY of SPAIN and PORTU- 
GAL. In 5 vols. 

' A general History of the Spanish and Portuguese 
Peninsula, is a great desideratum in our language", and 
we are glad to see it begun under such favorable aus- 
pices. We have seldom met with a narrative which 
fixes attention more steadily, and bears the reader's 
mind along more pleasantly." 

" In the volumes before us, there is unquestionable 
evidence of capacity for the task, and research in the 
execution."— U. S. Journal. 



HISTORY OF SWITZERLAND. 

" Like the preceding historical numbers of this valu- 
able publication, it abounds with interesting details, 
illustrative of the habits, character, and political com- 
plexion of the people and country it describes; and af- 
fords, in the small space of one volume, a digest of all 
the important facts which, in more elaborate histories, 
occupy five times the space."— Evening Post. 



TRAVELS, AtfNlTALS, &c 



NOTES on ITALY, during the years 1829-30. 
By Rembrandt Peale. In 1 vol. 8vo. 

" This artist will gratify all reasonable expectation ; 
he is neither ostentatious" nor dogmatical, nor too mi- 
nute ; he is not a partisan nor a carper ; he admires with- 
out servility, he criticises without malevolence; his 
frankness and good humor give an agreeable color and 
effect to all his decisions, and the object of them ; his book 
leaves a useful general idea of the names, works, and de- 
serts, of the great masters; it>is an instructive and enter- 
taining index." — Nat. Oaz. 

" We have made a copious extract in preceding columns 
from this interesting work of our countryman, Rembrandt 
Feale, recently published. It has received high commen- 
dation from respectable sources, which is justified by the 
portions we have seen extracted.'' — Commercial Advertiser. 

" Mr. Peale must be allowed the credit of candor and 
entire freedom from affectation in the judgments he has 
passed. At the same time, we should not omit to notice 
the variety, extent, and minuteness of his examinations. 
No church, gallery, or collection, was passed by, and most 
of the individual pictures are separately and carefully 
noticed." — Am. Quarterly Review. 

FRAGMENTS of VOYAGES and TRAV- 
ELS, including ANECDOTES of NAVAL 
LIFE ; intended chiefly for the Use of Young- 
Persons. By Basil Hall, Capt. R. N. In 
2 vols, royal 18mo. 

" Kis volumes consist of a melange of autobiography, 
naval anecdotes, and sketches of a somewhat discursive 
nature, which we have felt much pleasure iii perusing." 

"The title page to these volumes indicates their being 
chiefly intended for young persons, but we are much mis- 
taken if the race of gray-beards will be among the least 
numerous of the readers of 'midshipmen's pranks and 
the humors of the green room.' " — Lit. Gazette. 

A TOUR in AMERICA. By Basil Hall, 
Capt. R. N. In 2 vols. 12mo. 

SKETCHES OF CHINA, with Illustrations 
from Original Drawings. By W. W. Wood. 
In 1 vol. 12mo. 

" The residence of the author m China, during the 
years 182(5-7-8 and 9, has enabled him to collect much 
very curious information relative to this singular people, 
which he has embodied in his work; and will serve to 
gratify the curiosity of many whose time or dispositions 
do not allow them to seek, in the voluminous writings of 
the Jesuits and early travellers, the information contained 
in the present work. The recent discussion relative to 
the renewal of the East India Company's Charter, has 
excited much interest ; and among ourselves, the desire 
to be further acquainted with the subjects of 'the Celes- 
tial Empire.' has been considerably augmented." 

EXPEDITION to the SOURCES of the 
MISSISSIPPI, Executed by order of the 
Government of the United States. By Ma- 
jor S. H. Long. In 2 vols. 8vo. With Plates. 

HISTORICAL, CHRONOLOGICAL, GEO- 
GRAPHICAL, and STATISTICAL AT- 
LAS of NORTH and SOUTH AMERI- 
CA, and the WEST INDIES, with all 
their Divisions into States, Kingdoms, &c. 
on the Plan of Le Sage, and intended as a 
companion to Lavoisne's Atlas. In 1 vol. 
folio, containing 54 Maps. Third Edition, 
improved and enlarged. 



to render it worthy of the purpose for which it 
is intended. 

Embellishments, — L The Hungarian Prin- 
cess, engraved by Illman and Pillbrow, from a 
picture by Holmes. — 2. The Bower of Paphos, 
engraved by Ellis, from a picture by Martin. — 
3. The Duchess and Sancho, engraved by Du- 
rand, from a picture by Leslie. — 4. Richard and 
Salad in, engraved by Ellis-, from a picture by 
Cooper. — 5. The Rocky Mountains, engraved 
by Hatch and Smilie, from a picture by 
Doughty. — 6. Lord Byron in Early Youth, 
engraved by Ellis, from a picture by Saunders. 
— 7. Tiger Island, engraved by Neagle, from 
a picture by Stanfield.— 8. The Blacksmith, 
engraved by Kelly, from a picture by Neagle. 
— 9. The Tight Shoe, engraved by Kelly, from 
a picture by Richter. — 10. Isadore, engraved 
by Illman and Pillbrow, from a picture by 
Jackson. — 11. The Dutch Maiden, engraved 
by Neagle, from a picture by Newton. — 12. 
The Mother's Grave, engraved by Neagle, from 
a picture by Schaffer. 



ATLANTIC SOUVENIR FOR 1831. 

Embellishments. — 1. Frontispiece. The 
Shipwrecked Family, engraved by Ellis, from 
a picture by Burnet. — 2. Shipwreck off Fort 
Rouge, Calais, engraved by Ellis, from a pic- 
ture by Stanfield. — 3. Infancy, engraved by 
Kelly, from a picture by Sir Thomas Law- 
rence. — 4. Lady Jane Grey, engraved by Kelly, 
from a picture by Leslie. — 5. Three Score and 
Ten, engraved by Kearny, from a picture by 
Burnet. — 6. The Hour of Rest, engraved by 
Kelly, from a picture by Burnet. — 7. The Min- 
strel, engraved by Ellis, from a picture by Les- 
lie.— 8. Arcadia, engraved by Kearny, from a 
picture by Cockerell. — 9. The Fisherman's 
Return, engraved by Neagle, from a picture 
by Collins. — 10. The Marchioness of Carmar- 
then, granddaughter of Charles Carroll of Car- 
rollton, engraved by Illman and Pillbrow, from 
a picture by Mrs. Mee. — 11. Morning among 
the Hills, engraved by Hatch, from a picture 
by Doughty. — 12. Los Musicos, engraved by 
Ellis, from a picture by Watteau. 

A few copies of the ATLANTIC SOUVE- 
NIR, for 1830, are still for sale. 



THE BOOK of the SEASONS. By 
William Howitt. 

"Since the publication of the Journal of a Naturalist, 
no work at once so interesting and instructive as the 
Book of the Seasons has been submitted to the public. 
Whether in reference to the utility of its design, or the 
grace and beauty of its execution, it will amply merit the 
popularity it is certain to obtain. It is, indeed, cheering 
and refreshing to meet with such a delightful volume, so 
full of nature and truth — in which reflection and experi- 
ence derive aid from imagination — in which we are 
taught much ; but in such a manner as to make it doubt- 
ful whether we have not been amusing ourselves all the 
time we have been reading. 1 '— New Monthly Magazine. 

" The Book of the Seasons is a delightful book, and 
recommended to all lovers of nature."— Blackwood's Mag- 
azine. 



JUST PUBLISHED BY CAREY, LEA, & BLANCHARD. 



PRIVATE MEMOIRS or NAPOLEON 
BONAPARTE, from the French of M. 
Fauvelet de Bourrienne, Private Secre- 
tary to the Emperor. Second American 
Edition, complete in one volume. 
%* This edition contains almost a fourth 
more matter than the previous one, as in order 
to render it as perfect as possible, extracts have 
been given from the Memoirs from St. Helena, 
Official Reports, &c. &c. in all cases where 
they differ from the statements of M. de Bour- 
rienne. 

" This English translation, which has been 
very faithfully rendered, is still more valuable 
than the original work, as upon all points where 
any obliquity from other published recitals oc- 
curs, the translator has given several accounts, 
and thus, in the form of notes, we are present- 
ed with the statements obtained from Napo- 
leon's own dictation at St. Helena, from the 
Memoirs of the Duke of Rovigo, of General 
Rapp, of Constant, from the writings of the 
Marquis of Londonderry, &c\" — U. Ser. Jour. 
" Those who desire to form a correct esti- 
mate of the character of one of the most extra- 
ordinary men "that ever lived in the tide of 
time," will scarcely be without it. The present 
edition possesses peculiar advantages. 

The peculiar advantages of position in re- 
gard to his present subject, solely enjoyed by 
M. de Bourrienne, his literary accomplish 
ments and moral qualifications, have already 
obtained for these memoirs the first rank in 
contemporary and authentic history. In 
France, where they had been for years ex- 
pected with anxiety, and where, since the 
revolution, no work connected with that peri- 
od or its consequent events has created so 
great a sensation, the volumes of Bourrienne 
have, from the first, been accepted as the 
only trustworthy exhibition of the private life 
and political principles of Napoleon. 

" We know from the best political authority 
now living in England, that the writer's ac- 
counts are perfectly corroborated by facts." — 
Lit. Gaz. 

" The only authentic Life of Napoleon ex- 
tant." — Courier 

"This splendid publication that literally 
leaves nothing to be desired." — Atlas, 

"These volumes may be read with all the 
interest of a romance." — Courier. 

" No person who is desirous rightly to ap- 
preciate the character of Bonaparte, will ne- 
glect the perusal of this work; whoever 
wishes to know, not merely the General or 
the Emperor, but what the* man really was, 
will find him well pictured here." — Tivxes. 



The BRAVO, by the author of the " Spy," 

" Pilot," " Red Rover," &c. In 2 vols. 12rao. 

" Let us honestly avow in conclusion, that 
in addition to the charm of an interesting fic- 
tion to be found in these pages, there is more 
mental power in them, more matter that sets 
people thinking, more of that quality that is 
accelerating the onward movement of the 
world, than in all the Scotch novels that have 
so deservedly won our admiration." — New 
Monthly Magazine. 

"This new novel from the pen of our 
countryman, Cooper, will win new laurels for 
him. It is full of dramatic interest — " hair- 
breadth escapes" — animated and bustling 
scenes on the canals, in the prisons, on the 
Rialto, in the Adriatic, and in the streets of 
Venice." — N. Y. Courier <5f Enquirer. 

" Of the whole work, we may confidently 
say that it is very able — a performance of ge- 
nius and power." — Nat. Gazette. 

" The Bravo will, we think, tend mush to 
exalt and extend the fame of its author. We 
have hurried through its pages with an avidi- 
ty which must find its apology in the interest- 
ing character of the incidents and the very- 
vivid and graphic style in which they are de- 
scribed." 

By the same author. 
The HEIDEN-MAUER, or Pagan i . 

In 2 vols. 
SALMONIA; or, Days of Fly Fishing; by 

Sir Humphry Davy. 

" One of the most delightful labors of lei- 
sure ever seen ; not a few of the most beauti- 
ful phenomena of nature are here lucidly ex- 
plained." — Gentleman's Magazine. 

NATURAL HISTORY of SELBORNE 
and its INHABITANTS. By the Rev. 
Gilbert White. 18mo. 

The MECHANISM of the HEAVENS, by 

Mrs. Somerville. In 18mo. 

" We possess already innumerable dis- 
courses on Astronomy, in which the wonders 
of the heavens and their laws are treated of; 
but we can say most conscientiously that we 
are acquainted with none — not even La Place's 
own beautiful expose in his System du Monde, 
—in which all that is essentially interesting in 
the motions and laws of the celestial bodies, or 
which is capable of popular enunciation, is so 
admirably, so graphically, or we may add. so 
unaffectedly and simply placed before us. * * * 
Is it asking too much of Mrs. Somerville to ex- 
press a hope that she will allow this beautiful 
preliminary Dissertation to be printed^ sepa 



The completest personal recollections of rately, for the delight and instruction of thou- 



Napoleon that have appeared." — Morn. Post. 
" As a part of the history of the most ex- 
traordinary man, and the most extraordinary 
times that ever invited elucidation, these me- 
moirs must continue to the latest ages to be 
reaords of invaluable interest." — Lit. Gaz. 



sands of readers, young and old, who cannot 
understand, or are" too indolent to apply them- 
selves to the more elaborate parts of the work! 
If she will do this, we hereby promise to ex- 
ert our best endeavors to make its merits 
known." — Literary Gazette. 



MISCELLANEOUS. 



A MEMOIR OF SEBASTIAN CABOT, with 
a Review of the History of Maritime Dis- 
covery* Illustrated toy Documents from 
the Rolls, now first published* 

11 Put forth in the most unpretending manner, and 
without a name, this work is of paramount importance 
to the subjects of which it treats." — Literary Gazette. 
"The author has corrected many grave errors, and in 
general given us a clearer insight into transactions of 
considerable national interest." — lb. " Will it not," says 
the author, with just astonishment, " be deemed almost 
incredible, that the very instrument in the Records of 
England, which recites the Great Discovery, and plainly 
contemplates a scheme of Colonization, should, up to 
this moment, have been treated by her own writers as 
that which first gave permission to go forth and explore ?" 
— lb. "We must return to investigate several collateral 
matters which we think deserving of more space than we 
can this week bestow. Meanwhile we recommend the 
work as one of great value and interest." — lb. 

" The general reader, as well as the navigator and the 
curious, will derive pleasure and information from this 
well- written production." — Courier. 

'A specimen of honest inquiry. It is quite frightful to 
think of the number of the inaccuracies it exposes : we 
shall cease to have confidence in books." "The investi- 
gation of truth is not the fashion of these times. But 
every sincere inquirer after historical accuracy ought to 
purchase the book as a curiosity: more false assertions 
and inaccurate statements were never exposed in the 
same compass. It has given us a lesson we shall never 
forget, and hope to profit by."— Spectator. 



HISTORY OF THE NORTHMEN, OR NOR- 
MANS AND DANES; from the earliest 
times to the Conquest of England by 
William of Normandy* By Henry Whea* 
ton, Member of the Scandinavian and 
Icelandic Literary Societies of Copenha- 
gen. 

This work embraces the great leading features of Scan 
dinavian history, commencing with the heroic age, and 
advancing from the earliest dawn of civilization to the 
introduction of Christianity into the North— its long and 
bloody strife with Paganism — the discovery and coloniza- 
tion of Iceland, Greenland, and North America, by the 
Norwegian navigators, before the time of Columbus— the 
military and maritime expeditions of the Northmen— 
their early intercourse of commerce and war with Con- 
stantinople and the Eastern empire— the establishment 
of a Norman state in France, under Rollo. and the sub 
jugation of England, first by the Danes, under Canute 
tl»e Great, and" subsequently by the Normans, under 
Duke William, the founder of the English monarchy, 
It also contains an account of the mythology and litera- 
ture of the ancient North— the Icelandic language pre 
vailing all over the Scandinavian countries until the 
formation of the present living tongues of Sweden and 
Denmark— an analysis of the Eddas, Sagns, and various 
chronicles and songs relating to the Northern deities and 
heroes, constituting the original materials from which 
the work has been principally composed. It is intended 
to illustrate the history of France and England during 
the middle ages, and at the same time to serve as an 
introduction to the modem history of Denmark, Norway, 
and Sweden. 



LETTERS TO A YOUNG NATURALIST, 
on the Stndy of Nature, and Natural The- 
ology. By JAMES Ii. DRUMBIOND, M* D. 
&c« "With numerous engravings* 

"We know of no work, compressed within the same 
limits, which seems so happily calculated to generate in 
a young mind, and to renovate in the old, an ardent love 
of nature in all her forms." — Monthly Review. 

"We cannot but eulogize, in the warmest manner, the 
endeavor, and we must say the successful endeavor, of a 
man of science, like Dr. Drummond, to bring down so 
exalted a pursuit to the level of youthful faculties, and to 
cultivate a taste at once so useful, virtuous, and refined." 
—Jfeio Monthly Mag. 



PRIVATE MEMOIRS of NAPOLEON BO- 
NAPARTE, from the French of M. Fauve- 
let de Bourrienne, Private Secretary to 
the Emperor. 

The peculiar advantages of position in regard to 
his present subject, solely enjoyed by M. de Bourri- 
enne, his literary accomplishments and moral quali- 
fications, have already obtained for these memoirs the 
first rank in contemporary and authentic history. In 
France, where they had been for years expected with 
anxiety, and where, since the revolution, no work 
connected with that period or its consequent events 
has created so great a sensation, the volumes of Bour- 
rienne have, from the first, been accepted as the only 
trustworthy exhibition of the private life and political 
principles of Napoleon 

We know from the best political authority now liv- 
ing in England, that the writer's accounts are perfectly 
corroborated by facts."— Lit. Oaz. 

ANNALS of the PENINSULAR CAM- 
PAIGNS. By the Author of Cyril Thorn- 
ton. In 3 vols. 12mo. with plates. 

The HISTORY OF LOUISIANA, particu- 
larly of the Cession of that Colony to the 
United States of North America ; with an 
Introductory Essay on the Constitution and 
Government of the United States, by M. de 
Marbois, Peer of France, translated from 
the French by an American Citizen. In 
1 vol. 8vo. 

The PERSIAN ADVENTURER. By the 
Author of the Kuzzilbash. In 2 vols. 12mo. 

" It is full of glowing descriptions of Eastern life." — 
Courier. 

MORALS of PLEASURE, Illustrated by 
Stories designed for Young Persons, in 1 
vol. 12mo. 

41 The style of the stories is no less remarkable for its 
ease and gracefulness, than for the delicacy of its humor, 
and its beautiful and at times affecting simplicity. A 
lady must have written it— for it is from the bosom of 
woman alone, that such tenderness of feeling and such 
delicacy of sentiment — such sweet lessons of morality- 
such deep and pure streams of virtue and piety, gush 
forth to cleanse the juvenile mind from the grosser impu- 
rities of our nature, and prepare the young for lives of 
usefulness here, and happiness hereafter."— JV*. Y. Com. 
Advertiser. 

CLARENCE; a Tale of our own Times. By 
the Author of Redwood, Hope Leslie, &c. 
In 2 vols. 

AMERICAN QUARTERLY REVIEW, pub- 
lished on the first of March, June, Septem- 
ber, and December. Price $5 per aim. 
%* A few complete Sets of the Work are still for 

sale. 

CONSIDERATIONS ON THE CURREN- 
CY AND BANKING SYSTEM OF THE 
UNITED STATES. By Albert Galla- 
tin. 

SONGS of the AFFECTIONS. By Felicia 
Hemans. Royal 18mo. 



SCOTT, COOPER, AND WASHINGTON IRVING, 



BY SIR WALTER SCOTT. 



COUNT ROBERT OF PARIS, a Tale of 
the Lower Empire. By the Author of Wa- 
verley. In 3 vols. 

"The reader will at once perceive that the subject, 
the characters and the scenes of action, could not have 
been better selected for the display of the various and un- 
equalled powers of the author. All that is glorious in arts 
and splendid in arms— the glitter of armor, the pomp of 
war, and the splendor of chivalry— the gorgeous scenery 
of the Bosphorus— the ruins of Byzantium— the magnifi- 
cence of the Grecian capital, and the richness and volup- 
tuousness of the imperial court, will rise before the reader 
in a succession of beautiful and dazzling images." — Com- 
mercial Advertiser. 

AUTOBIOGRAPHY OF SIR WALTER 
SCOTT. With a Portrait. 

" This is a delightful volume, which cannot fail to sat- 
isfy every reader, and of which the contents ought to be 
known to all those who would be deemed conversant with 
the literature of our era."— National Gazette. 

HISTORY OF SCOTLAND. In 2 vols. 

" The History of Scotland, by Sir Walter Scott, we do 
not hesitate to declare, will be, if possible, more exten- 
sively read, than the most popular work of fiction, by the 
same prolific author, and for this obvious reason : it com- 
bines much of the brilliant coloring of the Ivanhoe pic- 
tures of by-gone manners, and all the graceful facility of 
style and picturesqueness of description of his other 
charming romances, with a minute fidelity to the facts 
of history, and a searching scrutiny into their authenti- 
city and relative value, which might put to the blush 
Mr. Hume and other professed historians. Such is the 
magic charm of Sir Walter Scott's pen, it has only to 
touch the simplest incident of every-day life, and it starts 
up invested with all the interest of a scene of romance ; 
and yet such is his fidelity to the text of nature, that the 
knights, and serfs, and collared fools with whom his in- 
ventive geuiu6 has peopled so many volumes, are regarded 
by us as not mere creations of fancy, but as real flesh and 
blood existences, with all the virtues, feelings and errors 
of common-place humanity." — Lit. Gazette. 

TALES of a GRANDFATHER, being a 
series from French History. By the Author 
of Waverley. 



LIONEL LINCOLN, or the LEAGUER of 

BOSTON, 2 vols. 
The LAST of the MOHICANS, 2 vols. 

12mo. 
The PRAIRIE, 2 vols. 12mo. 



BY WASHINGTON IRVING. 



BY MR. COOPER. 



THE BRAVO. By the Author of the Spy, 
Pilot, &c. In 2 vols. 

The WATER-WITCH, or the SKIMMER 
of the SEAS. In 2 vols. 

"We have no hesitation in classing this among the 
most powerful of the romances of our countryman."— 
U. States Gazette. 

THE HEIDENMAUER; or, The Benedic- 
tines. 2 vols. 

New Editions of the following Works by the 

same Author. 
NOTIONS OF THE AMERICANS, by a 

Travelling Bachelor, 2 vols. 12mo. 
The WEPT OF WISH-TON-WISH, 2 vols. 

12mo. 
The RED ROVER, 2 vols. 12mo. 
The SPY, 2 vols. 12mo. 
The PIONEERS, 2 vols. 12mo. 
The PILOT, a Tale of the Sea, 2 vols. 12mo. 



VOYAGES and ADVENTURES of the 
COMPANIONS of COLUMBUS. By 
Washington Irving, Author of the Life 
of Columbus, &c. 1 vol. 8vo. 
" Of the main work we may repeat that it possesses 
the value of important history and the magnetism of ro- 
mantic adventure. It sustains in every respect the repu- 
tation of Irving." M We may hope that the gifted author 
will treat in like manner the enterprises and exploits of.' 
Pizarro and Cortes ; and thus complete a series of elegant 
recitals, which will contribute to the especial gratifica- 
tion of Americans, and form an imperishable fund of 
delightful instruction for all ages and countries. 1 '— Nat 
Gazette. 

" As he leads us from one savage tribe to another, as 
he paints successive scenes of heroism, perseverance and 
self-denial, as he wanders among the magnificent scenes 
of nature, as he relates with scrupulous fidelity the 
errors, and the crimes, even of those whose lives are for 
the most part marked with traits to command admira- 
tion, and perhaps esteem — everywhere we find him the 
same undeviating, but beautiful'moralist, gathering from 
every incident some lesson to present in striking lan- 
guage to the reason and the heart."— Jim. Quarterly Re- 
view. 

" This is a delightful volume; for the preface truly says 
that the expeditions narrated and springing out of the 
voyages of Columbus may be compared with attempts of 
adventurous knights-errant to achieve the enterprise left 
unfinished by some illustrious predecessors. Washington 
Irving's name is a pledge how well their stories will be 
told : and we only regret that we must of necessity defer 
our extracts for a week."— London Lit. Gazette. 

A CHRONICLE of the CONQUEST of 

GRENADA. By Washington Irving. 

Esq. In 2 vols. 

" On the whole, this work will sustain the high fame 
of Washington Irving. It fills a blank in the historical 
library which ought not to have remained so long a 
blank. The language throughout is at once chaste and 
animated ; and the narrative may be said, like Spenser's 
Fairy Queen, to present one long gallery of splendid pic 
tures." — Lond. Lit. Gazette. 

"Collecting his materials from various historians, and 
adopting in some degree the tone and manner of a monk- 
ish chronicler, he has embodied them in a narrative which 
in manner reminds us of the rich and storied pages of 
Froissart. He dwells on the feats of chivalry performed 
by the Christian Knights, with all the ardor which might 
be expected from a priest, who mixed, according to the 
usage of the times, not only in the palaces of courtly 
nobles, and their gay festivals, as an honored and wel- 
come guest, but who was their companion in the camp, 
and their spiritual and indeed bodily comforter and as- 
sistant in the field of battle.— Am. Quarterly Review. 

New Editions of the following Works by the 
same Author. 

The SKETCH BOOK, 2 vols. 12mo. 

KNICKERBOCKER'S HISTORY of NEW 
YORK, revised and corrected. 2 vols. 

BRACEBRIDGE HALL, or the HUMOR- 
ISTS, 2 vols. 12mo. 

TALES of a TRAVELLER, 2 vols. 12mo. 



CLASSICAL LITERATURE. 



INTRODUCTION to the STUDY of the 
GREEK CLASSIC POETS, for the use of 
Young* Persons at School or College. 

Contents. — General Introduction; Ho- 
meric Questions ; Life of Homer ; Iliad ; 
Odyssey; Margites; Batrachomyomachia ; 
Hymns; Hesiod. By Henry Nelson Cole- 
ridge. 

" YYe have been highly pleased with this little volume. 
This work supplies a want which we have often painfully 
felt, and affords a manual which we should gladly see 
placed in the hands of every embryo undergraduate. 
We look forward to the next portion of this work with 
very eager and impatient expectation. 1 '— British Critic. 

" Mr. Coleridge's work not only deserves the praise of 
clear, eloquent and scholar like exposition of the prelimi- 
nary matter, which is necessary in order to understand 
and enter into the character of the great Poet of anti- 
quity ; but it has likewise the more rare merit of being 
admirably adapted for its acknowledged purpose. It is 
written in thai fresh and ardent spirit, which to the con- 
genial mind of youth, will convey instruction in the 
most effective manner, by awakening the desire of it; 
and by enlisting the lively and buoyant feelings in the 
cause of useful and improving study; while, by its preg- 
nant brevity, it is more likely 1o stimulate than to super- 
sede more profound and extensive research. If then, as it 
is avowedly intended for the use of the younger readers 
of Homer, and, as it is impossible not to discover, with a 
more particular view to the great school to which the au- 
thor owes his education, we shall be much mistaken if it 
does not become as popular as it will be useful in that 
celebrated establishment." — Quarterly Review. 

11 We sincerely hope that Mr. Coleridge will favor us 
with a continuation of his work, which he promises." — 
Gent. Mag. 

" The author of this elegant volume has collected a vast 
mass of valuable information. To the higher classes of 
the public schools, and young men of universities, this 
volume will be especially valuable; as it will afford an 
agreeable relief of light reading to more grave studies, at 
once instructive and entertaining."— Wesleyan Methodist 
Magazine. 

ATLAS OF ANCIENT GEOGRAPHY, con- 
sisting of 21 Colored Maps, with a complete 
Accentuated Index. By Samuel Butler, 
D. D., F. R. S. &c. Archdeacon of Derby. 

By the same Author. 

GEOGRAPHIA CLASSICA: a Sketch of 
Ancient Geography, for the Use of Schools. 



MECHANICS, MANUFACTURES, Ac. 



In 8vo. 



A PRACTICAL TREATISE on RAIL- 
ROADS, and INTERIOR COMMUNI- 
CATION in GENERAL— containing an 
account of the performances of the different 
Locomotive Engines at, and subsequent to, 
the Liverpool Contest; upwards of two 
hundred and sixty Experiments with Tables 
of the comparative value of Canals and Rail- 
roads, and the power of the present Locomo- 
tive Engines. By Nicholas Wood, Colliery 
Viewer, Member of the Institution of Civil 
Engineers, &c. 8vo. with plates. 

" In this, the able author has brought up his treatise to 
the date of the latest improvements in this nationally 
important plan. We consider the volume to be one of 
great general interest."— Lit. Oaz. 

"We must, injustice, refer the reader to the work 
itself, strongly assuring him that, whether he be a man of 
science, or one totally unacquainted with its technical 
difficulties, he will here receive instruction and pleasure, 
in a degree which we have seldom seen united before."— 
Monthly Rev. 

REPORTS on LOCOMOTIVE and FIXED 
ENGINES. By J. Stephenson and J. 
Walker, Civil Engineers. With an Ac- 
count of the Liverpool and Manchester Rail- 
road, by H. Booth. In 8vo. with plates. 

MILLWRIGHT and MILLER'S GUIDE. 
By Oliver Evans. New Edition, with ad- 
ditions and corrections, by the Professor of 
Mechanics in the Franklin Institute of 
Pennsylvania, and a description of an im- 
proved Merchant Flour-Mill, with engrav- 
ings, by C. & O. Evans, Engineers. 

THE NATURE and PROPERTIES of the 
SUGAR CANE, with Practical Directions 
for its Culture, and the Manufacture of its 
various Products; detailing- the improved 
Methods of Extracting, Boiling", Refining-, 
and Distilling*; also Descriptions of the Best 
Machinery, and useful Directions for the 
general Management of Estates. By George 
Richardson Porter. 



"This volume contains a valuable mass of scientific 
and practical information, and is, indeed, a compendium 
of everything interesting relative to colonial agriculture 
and manufacture." — Intelligencer. 

"We can altogether recommend this volume as a most 
valuable addition to the library of the home West India 
merchant, as well as that of the resident planter.'"— Lit. 
Gazette. 

"This work may be considered one of the most valua- 
ble books that has yet issued from the press connected 
with colonial interests; indeed, we know of no greater 
service we could render West India proprietors, than in 
recommending the study of Mr. Porter's volume." — Spec- 
tator. 

" The work before us contains such valuable, scientific, 
and practical information, that we have no doubt it will 
find a place in the library of every planter and person 
connected with our sugar colonies. 1 '— Monthly Magazine. 

A TREATISE on MECHANICS. By James 
Renwick, Esq. Professor of Natural and 
Experimental Philosophy, Columbia College, 
N. Y. In 8vo. with j/iumerous engravings. 



THE 

NATIONAL SCHOOL MANUAL: 

A 

REGULAR AND CONNECTED COURSE OF ELEMENTARY STUDIES, 

EMBRACING 

THE NECESSARY AND USEFUL BRANCHES OF A COMMON EDUCATION, 



IN FOUR PARTS, WITH A QUARTO ATLAS. 



COMPILED FROM THE LATEST AND MOST APPROVED AUTHORS, 

BY M. R. BARTLETT. 



The plan of this work was the suggestion of the late 
Governor Clinton, whose zeal and efforts in the cause 
of our Public Schools, will be cherished with grateful 
remembrance to the latest posterity ; and this work, so 
far as it had advanced, up to the time of his lamented 
death, received his favorable regard and patronage. 

The object of the National School Manual, is to 
furnish a System of instruction, for a thorough English 
education, in a plain, practical, and progressive Series 
of Lessons, collaterally arranged. 

It is believed that the plan of this work is sufficiently 
wide and comprehensive for all the purposes of a good 
English Education, and that it is capable of advancing 
the pupil much faster in his studies, and to much higher 
attainments in the useful sciences, than is possible in 
the present mode, with the help of the best teachers. 

Tin; practical results of a general adoption of the 
National School Manual will be : 

1st. To introduce system, uniformity and order into 
our Schools. 2d. To define and regulate the duties of 
teachers, and give them the means of being more tho- 
rough, precise, and useful. 3d. To present to the opening 
minds of pupils, the various subjects of human science, 
in a clear and lucid manner, and with all the advan- 
tages of natural order, and philosophical arrangement, 
adapted to the progress of knowledge: and, 4th. To 
Parents and Guardians, exemption from the vexation 
and expense of changing the whole catalogue of School 
Books, and the whole course of studies, with every 
change of School or Teacher — a thing of very frequent 
occurrence in our Country Schools. As to the saving 
of expense in the article of School Books, the entire 
cost of the Common School Manual, embracing the 
Primer and the Four Parts, of upwards of 1500 pages, 
for the whole course of a good English education, and an 
Atlas of 20 maps, is between three and four dollars. 

From the Teachers of Public Schools in the city of New- 
York. 
We have examined the National School Manual, and 
are pleased with the plan. From our knowledge of the 
various systems pursued in the country schools, many 
of which, upon the change of teachers, serve rather to 
retarl, than advance, the pupil, we do not hesitate to 
recommend the Manual, as having not only a tendency 
to uniformity and order, but also to save'expense, the 
complaint of which is without parallel. 

LOYD D. WINDSOR, 
Teacher of Public School, No. 1 

JOSEPH BELDEN, 
Teacher of Public School, No. 11. 

A. DE MONTFREDY. 
Teacher of Public School, No. 10. 



be put into the hands of a pupil, he wfl4 lose his time, 
and what is worse, he will probably contract a disgust 
for learning. The great art of teaching consists in 
beginning with the simplest elements, and advancing 
gradually to things more difficult as the capacity of ac- 
quiring knowledge expands, presenting something new 
to arrest the attention and to exercise the ingenuity 
of the pupil. To answer these ends, the work of Mr. 
Bartlett seems to me well suited. If these small vol- 
umes be thoroughly studied, I am persuaded that the 
pupil will be better prepared to transact the business of 
life, and by his own exertions to improve himself after 
he leaves school, than if he had spent twice the time 
under an ill-arranged system of instruction. 

It will, doubtless, be difficult to introduce a uniform 
system of instruction into our common schools; vet 
the object is so desirable, that it deserves a vigorous 
and persevering effort ; and I indulge the hope that the 
day is not far distant, when the " National School Man- 
ual," improved and enlarged by its able and experienced 
author, will be very generally adopted. 

JAMES CARNAHAN. 

Nassau Hall, April 27, 1832. 



Februarys, 1830. 

From, the Rev. James Carvahav, President of Princeton 
College. 

Having examined the general plan of the 1st, 2d, and 
3d parts of the " National School Manual," and hav- 
ing also taken a cursory view of some of the details, I 
am satisfied that it is a work of no common merit. 

The evils which this work proposes to remedy are 
srreat and generally' felt by parents and instructors. 
The expense of books, according to the course hereto- 
fore pursued, is a very serious inconvenience ; and the 
loss of time and labor arising from the want of a con- 
nected series of instruction adapted to the capacities 
of children and youth, is a consideration of vast mo- 
ment. 

Comparatively few instructors are competent to select, 
from the great number of books now used in common 
schools, those adapted to the improving capacities of 
their pupils. If a book, which he cannot understand, 



From the Rev. Charles S. Stewart, Chaplain in the United 
States Navy— Author of a Journal of Voyages to the 
Pacific, %c. 8fc. 

I have examined with mueft care, and great satisfac- 
tion, the "National School Manual," compiled by 
M. R. Bartlett. The opinion I have formed of its merits, j 
is of little importance, after the numerous and highly 
respectable testimonials to its value alreadv in vour 
possession. 

A work of this kind has long been a desideratum in 
the economy of our public schools, and I am persuaded 
that the advantages which this compilation is calculated 
to secure to pupils, teachers, and parents, need only to 
be appreciated to secure its introdection throughout our 
country. It will be found on trial, I think, greatlv to 
aid the instructor in his arduous service, while the pupH 
cannot fail, in the use of it, if I am not mistaken, to \ 
make a more rapid and understanding progress than by j 
the method now generally pursued. To teacher and 
scholar the importance and value of the system, I douftr 
not, would be fully shown after a very brief trial, while 
the parent and guardian would soon learn its advantage 
in an exemption from the heavy tax now knposed on 
them by a constant change of books. 

I should be happy to see the Manual in every common 
school in the Union, from the con\i?tion that the best 
interests of education would be promoted by it. 

(Signed) CHAS. SAML. STEWART. 

Chaplain U. S. Navv. 

New -York, March 30, 1832. 



I have examined with care and a high degree of in- 
terest the work called the "National School Manual," 
by Mr. M. R. Bartlett. and am so well satisfied with its 
merits, and that it will eventually be adopte&in ail our 
common schools, to the exclusion of every other work 
of the kind now in use. that I feel authorized to exert 
my influence to have the work introduced forthwith 
into mv school. 

J AS. W. FAIRCHILD, 
Principal of the Hudson Academy. 

Hudson, Jan. 23> 1832. 



The Publishers hare similar letters from fifty or 
sixty Teachers of the highest respectability. 




i-H (N eo ^ »o 



H « « ^ «} 



rHOiCOTf»OCOl^OOCr- 



EDUCATION. 



A New Abridgement of AINSWORTH'S 
DICTIONARY, English and Latin, for 
the use of Grammar Schools. By John 
Dymock, LL. D., with Notes, by Charles 
Anthon. 1 vol. 18mo. 

In this edition are introduced several alterations and 
improvements, for the special purpose of facilitating 
the labor and increasing the knowledge of the young 
scholar. 

GREEK and ENGLISH LEXICON. By D. 

Donnegan. Abridged for the use of Schools. 

In 1 vol. royal 18mo., containing above 800 

pages. 

This work is printed on a handsome distinct type, 
and contains as much matter as many of the larger lexi- 
cons ; but owing to the form in which it is printed, it is 
sold at such price as to be within the reach of all stu- 
dents. It offers more advantages to the young student 
than any other lexicon now in use. The vocabulary 
is more extensive and complete — comprising not only 
words found in the classics, but also such as are found in 
the writings of Hippocrates and the Greek physicians. 
The meanings attached to words by the several writers 
are also given. 

Words are given in alphabetical order in every poeti- 
cal and dialectic variety. 

The conjugation of verbs and flection of nouns are 
more complete than in other lexicons; — the meanings 
of words fuller and more correct — there being first a 
primary and then a secondary meaning, each distin- 
guished from the metaphorical and idioraatical. Phrases 
are also given when they note any peculiarity in signi- 
fication. The etymology of words is only omitted where 
it is confused or disputed. There is nothing left out 
which the young student would find necessary in study- 
ing the classics, and which would enable him to under- 
stand the true meaning of a word. In short, in this 
work the essential advantages of a good Dictionary 
are combined with those of a good Grammar — advan- 
tages not found in any Greek and English lexicon now 
used. 

ELEMENTS of MECHANICS. By James 
Renwick, Esq., Professor of Natural and 
Experimental Philosophy, Columbia College, 
N. Y. In 8vo. with numerous Engravings. 
" We think this decidedly the best treatise on Me- 
chanics, which has issued from the American press, that 
we have seen ; one, too, that is alike creditable to the 
writer, and to the state of science in this country." — 
American Quarterly Review. 

ELEMENTS of OPTICS. By David Brew- 
ster. First American edition, with Notes 
and Additions, by A. D. Bache, Professor of 
Natural Philosophy and Chemistry in the 
University of Pennsylvania. 18mo. 

44 The author has given proof of his well-known in- 
dustry, and extensive acquaintance with the results of 
science in every part of Europe." — Monthly Mag. 

41 The subject is, as might be expected, ably treated, 
and clearly illustrated." — U. S. Jour. 

A TREATISE on HYDROSTATICS and 
PNEUMATICS. By the Rev. Dionysius 
Lardner, LL. D. F. R. S. &c. First Amer- 
ican from the first London edition, with 
Notes by Benjamin F. Joslin, M. D., Pro- 
fessor of Natural Philosophy in Union Col- 
lege. 

44 It fully sustains the favorable opinion we have al- 
ready expressed as to this valuable compendium of mod- 
ern science." — Lit. Oaz. 

44 Dr. Lardner lias made a jrooduse of his acquaintance 
with the familiar facts which illustrate the principles of 
science."— Monthly Mag. 

44 It is written with a full knowledge of the subject, 
and in a popular style, abounding in practical illustra- 
tions of the abstruse operations of these important 
sciences." — U. S. Jour. 



An ESSAY on MORAL CULTURE, ad- 
dressed to Parents and Teachers. By M. M. 
Carll. 18mo. 

An ELEMENTARY TREATISE on AL- 
GEBRA, Theoretical and Practical ; with 
attempts to simplify some of the more diffi- 
cult parts of the science, particularly the 
demonstration of the Binomial Theorem, in 
its most general fonn ; the Solution of 
Equations of the higher orders ; the Summa- 
tion of Infinite Series, &c. By J. R. Young. 
First American edition, with Additions and 
Improvements, by Samuel Ward, Jun. 8vo. 
41 A new and ingenious general method of solving 
Equations has been recently discovered by Messrs. H. 
Atkinson, Holdred, and Horner, independently of each 
other. For the best practical view of this new method 
and its applications, consult the Elementary Treatise on 
Algebra, by Mr. J. R. Young, a work which deserves our 
cordial recommendation." — Dr. Gregory's edition of Hut- 
ton's Mathematics. 

44 For the summation of Infinite Series the author 
gives a new and ingenious method, which is very easy 
and extensive in its application." — Newcastle Mag. 

By the same Author. 
ELEMENTS of GEOMETRY; containing 
a new and universal Treatise on the Doe- 
trine of Proportions, together with Notes, 
in which are pointed out and connected 
several important errors that have hitherto 
remained unnoticed in the writings of Ge- 
ometers. Also, an Examination of the vari- 
ous Theories of Parallel Lines that have 
been proposed by Legendre, Bertrand, Ivory, 
Leslie, and others. 

44 His observations on the theory of parallel lines, the 
labor he has bestowed on the doctrines of proportion, as 
well as his corrections of many errors of preceding Ge- 
ometers, and supplying their defects, together with his 
minute attention to accuracy throughout, may be justly 
considered as rendering his performance valuable, espe- 
cially to the learner.*' — Philosophical Magazine. 

44 We have never seen a work so free from pretension 
and of such great merit. Various fallacies latent in the 
reasoning of some celebrated mathematicians, both of 
ancient and modern date, are pointed out and discussed 
in a tone of calm moderation, which we regret to say is 
not always employed in the scientific world.'*— Monthly 
Magazine. 

41 This is a work of valuable information, the concep- 
tion of a most enlightened mind, and executed with a 
simplicity which cannot but carry the important truth 
it speaks of home to the conviction of every under- 
standing." — Weekly Times. 

The ELEMENTS of ANALYTICAL GE- 
OMETRY ; comprehending the Doctrine 
of the Conic Sections, and the General 
Theory of Curves and Surfaces of the sec- 
ond order, with a variety of local Problems 
on Lines and Surfaces. Intended for the 
use of Mathematical Students in Schools 
and Universities. 

44 If works like the present be introduced generally 
into our schools and colleges, the continent will not long 
boast of its immense superiority over the eountry of 
Newton, in every branch of modern analvtical science, 

— Atlas. 

ELEMENTS or PLANE and SPHERICAL 
TRIGONOMETRY, comprehending the 
Theory of Navigation and of Nautical As- 
tronomy. 

ELEMENTS of MECHANICS, comprehend- 
ing Statics and Dynamics, 



EDUCATION. 



LESSONS on THINGS, intended to improve 
Children in the Practice of Observation, Re- 
flection and Description, on the System of 
Pestalozzi, edited by John Frost, A. M. 

The publishers request the attention of 
teachers, school committees, and all who are 
desirous of improving the methods of instruc- 
tion, to this work, which is on a plan hitherto 
unattempted by any school-book in this coun- 
try, and which has been attended with extra- 
Drdinary success in England. 

The following remarks on the work are ex- 
tracted from the " Quarterly Journal of Edu- 
cation." 

" This little volume is a ■ corrected and re-corrected' edi- 
tion of lessons actually given to children, and, therefore, 
possesses a value to which no book made in the closet 
;an lay claim, being the result of actual experiment. 
The work consists of a number of lessons, divided into 
five series; beginning with subjects the most easy and 
elementary, it gradually increases in difficulty, each suc- 
cessive step being adapted to the mind of the child as it 
acquires fresh stores of knowledge. 

" Every part of these lessons is interesting to the child, 
both on account of the active operation into which his 
own mind is necessarily called by the manner in which 
the lessons are given ; and also by the attractive nature 
of many of the materials which form the subject of the 
lessons. In the first and most elementary series, the pupil 
is simply taught to make a right use of his organs of 
sense, and to exercise his judgment so far only as relates 
to the objects about him; and accordingly the matter 
brought before him at this stage, is such that its obvious 
properties can be discovered and described by a child who 
has acquired a tolerable knowledge of his mother tongue." 

OUTLINES of HISTORY, from the Earliest 
Records to the Present Time. Prepared for 
the Use of Schools, with Questions, by John 
Frost, A. M. 

" The main object of the work is, by giving a selection 
of interesting and striking facts from more elaborate his- 
tories, properly and carefully arranged, with chronological 
tables, to render the study of general history less dry and 
repulsive than it has been heretofore. This, we think is 
fully accomplished. Very great care appears tq.have been 
bestowed on the selections, and in arranging the chrono- 
logical tables, as well as in the classification of the his- 
torical matter into parts and chapters. The work will 
sufficiently recommend itself to all who examine it."— 
Sat. Evening Post. 

"To concentrate in one comparatively small volume, a 
complete epitome of the entire history of the world, an- 
cient and modern, so treated as to present a correct image 
of it, would seem to be an object to be wished for, rather 
than expected ; the ' Outlines of History,' however, realize 
this object."— Asiatic Journal. 

"We consider that Mr. F has done a service to schools, 
by the time and labor which he has bestowed upon this 
work ; the marginal dates will be found of great service, 
but the chapters of questions upon the text, and upon the 
maps, to illustrate the geography of the history, will es- 
peeially recommend the work to the attention of teach- 
ers."— U. S. Gazette. 

Philadelphia, July J(M, 1831. 
'The 'Outlines of History.' I consider an excellent 
class-book of general history for the use of schools. The 
questions added by Mr. Fr.-)3t, are a most valuable auxili- 
ary for the teacher as'well as the pupil. I shall use the 
'Outlines' in my school, and cordially recommend it to 
parents and teachers. S. C. WALKER." 

Philadelphia, April 30th, 1831. 
" Dear Sir,— I have just received a copy of your edition 
of the 'Outlines of History.' From a cursory perusal, I 
am disposed to give it a high rank as a school-book. So 
well satisfied am I with the arrangement and execution 
of the work, that I intend to put it immediately into the 
hands of a class in my own school. 

" Verv respectfully, your obedient servant, 
" Mr. Johw Frost." " LEVI FLETCHER. 



FRENCH. 



BY A. BOLMAR. 



A COLLECTION of COLLOQUIAL 
PHRASES on every Topic necessary to main- 
tain Conversation, arranged under different 
heads, with numerous remarks on the peculiar 
pronunciation and use of various words — the 
whole so disposed as considerably to facilitate 
the acquisition of a correct pronunciation of 
the French. By A. Bolmar. One vol. 18mo. 

A SELECTION of ONE HUNDRED 
PERRIN'S FABLES, accompanied by a Key, 
containing the text, a literal and free trans- 
lation, arranged in such a manner as to point 
out the difference between the French and the 
English idiom, also a figured pronunciation of 
the French, according to the best French works 
extant on the subject ; the whole preceded by 
a short treatise on the sounds of the French 
language, compared with those of the English. 

Les AVENTURES de TELEMAQUE 
par FENELON, accompanied by a Key to 
the first eight books ; containing like the Fa- 
bles — the Text — a Literal — and Free Trans- 
lation ; intended as a Sequel to the Fables. 

The expression 'figured pronunciation,' is above em- 
ployed to express that the words in the Key to the French 
Fables are spelt and divided as they are pronounced. It is 
what Walker has done in his Critical Pronouncing Dic- 
tionary ; for instance, ho indicates the pronunciation of the 
word enough, by dividing and spelling it thus, e-nuf. In 
the same manner I indicate the pronunciation of the word 
comptaient thus, kon-te. As the understanding of the 
figured pronunciation of Walker requires the student to 
be acquainted with the primitive sounds of the English vow- 
els, he must likewise, before he can understand the figured 
pronunciation of the French, make himself acquainted with 
the 20 primitive sounds of the French vowels. This any 
intelligent person can get from a native, or from anybody 
who reads French well, in a few hours. 

A COMPLETE TREATISE on the GEN- 
DERS of FRENCH NOUNS; in a small 
pamphlet of fourteen pages. 

This little work, which is the most complete 
of the kind, is the fruit of great labor, and will 
prove of immense service to every learner. 

ALL THE FRENCH VERBS, both REG- 
ULAR and IRREGULAR, in a small volume. 

The verbs etre to be, avoir to have, parler to speak, 
Jlnir to finish, recevoir to receive, vendre to sell, se 
lever to rise, se Men j>orter to be well, s'en dller to go 
away, are here all conjugated through — affirmatively 
— negatively — interrogatively — and negatively and in- 
terrogatively — an arrangement which will greatly fa- 
cilitate the scholar in his learning ihe French verbs, 
and which will save the master the trouble of explain- 
ing over and over again what may be much more 
easily learned from books, thus leaving him more time 
to give his pupil, during the lesson, that instruction 
which cannot be fbund'in books, but which must be 
learned from a master. 



NEUMAN'S SPANISH and ENGLISH 
DICTIONARY. New Edition, in one vol. 
16mo. 



LIBRARY OF THE MEDICAL SCIENCES. 



CAREY, IiEA & BLAffCHARD 

Have just published — 

THE 

CYCLOPEDIA 



OF 



PRACTICAL MEDICINE 



AND 



SURGERY, 



DIGEST OF MEDICAL LITERATURE. 

EDITED BY • 

ISAAC HAYS, M. D. 



PART I. 



CONTAINING 



A; In Composition .... By Dr. 

Abaptiston 

Abbreviation 

Abdomen, Anatomy . . Dr. 

— - Surg. Anat. 

< Abnormal 

Anat 

-t Physiology Dr. 

— Pathology ~) 

(Gen.) 5 

Wounds of Dr. 

. Contusions of 

Raptures of 

Effusions into 

. Abnormal ? -pv 

adhesions of 

Fistulse of 

Foreign 

bodies in 

Loose bo- 
dies in 

Tumours in 

Fatty tu-£ 

mours of 



Hats. 

Do. 
Do. 

Geddings. 
Do. 

Do. 

Hats. 

Do. 

K. COATES. 

Do. 
Do. 
Do. 

Hats. 

Do. 

Do. 

Do. 
Do. 

R. CoiTES. 



Ab dtps e y n of E ??!::?^ B yDH.E.c OATE , 



■ Phlegmon") 
and abscesses of 5 
Pulsations in 



Dr. Hats. 



Abductors 

Abepithymia 

Aberration 

Abies 

Abirritation 

Ablactation 

Ablation 

Abortion, (Obstet.) .. 

(Med. Leg.) 

Abortives 

Abrasion 

Abscess, Pathological"^ 
Anatomy of Phleg- > 
monous j 

Cold „ 

Metastatic . . 

Treatment of 



Dr. 
Dr. 



Dr. 
Dr. 

Dr. 



Do. 

Do. 

Do. 

Do. 
Wood. 
Hats. 

Do. 

Do. 

Dewees. 

Griffith. 

Do. 
Hats 



Dr. Harris. 

Do. 
Do. 
Do. 



CONTRIBUTORS 



CYCLOPEDIA 



OP 



PRACTICAL MEDICINE 



SURGERY. 



FRANKLlft BACHE, M. D., Lecturer on 
Medical Chemistry, and Physician to the 
Penitentiary. 

N. CHAPMAN, M. D., Professor of the 
Institutes and Practice of Physic and Cli- 
nical Practice in the University of Penn- 
sylvania. 

E. H. COATES, M. D., Lecturer on the 
Practice of Medicine in the School of 
Medicine. 

REYNELL COATES, M. D., of Philadel- 
phia. 

D. FRANCIS CONDIE, M. D., of Phila- 
delphia. 

WM. P. DEWEES, M. D., Adjunct Pro- 
fessor of Midwifery in the University of 
Pennsylvania. 

S. HENRY DICKSON, M. D., Professor 
of the Institutes and Practice of Medicine 
in the Medical College of South Caro- 
lina. 

ROBLEY DUNGLISON, M. D., Professor 
of Materia Medica, Therapeutics, Hy- 
giene, and Medical Jurisprudence, in the 
University of Maryland. 

GOUVERNEUR EMERSON, M. D. of Phi- 
ladelphia. 

E. GEDD1NGS, M. D., Professor of Ana- 
tomy and Physiology in the University 
of Maryland. 

W. W. GERHARD, M. D. of Philadelphia. 
R. E. GRIFFITH, M. D. of Philadelphia. 
THOMAS HARRIS, M.D., Surgeon United 
States' Navy. 



GEORGE HAY WARD, M. D., Junior Sur- 
geon to the Massachusetts General Hos- 
pital. 

H. L. HODGE, M. D., one of the Physi- 
cians to the Pennsylvania Hospital. 

WM. E. HORNER, M. D., Professor of 
Anatomy in the University of Pennsyl- 
vania. 

ANSEL W. IVES, M. D. of New York. 

SAMUEL JACKSON, M. D., Assistant to 
the Professor of the Institutes and Prac- 
tice of Medicine in the University of 
Pennsylvania. 

J. K. MITCHELL, M. D., one of the Phy- 
sicians to the Pennsylvania Hospital. 

VALENTINE MOTT, M. D., Professor of 
Pathological and Operative Surgery in 
the College of Physicians and Surgeons 
of New York. 

J. RANDOLPH, M. D., one of the Sur- 
geons of the Philadelphia Alms-house 
Infirmary. 

JOSEPH M. SMITH, M. D., Professor of 
the Institutes and Practice of Medicine 
in the College of Physicians and Sur- 
geons, New York. 

A. F. VACHE, M. D. of New York. 

JOHN C. W r ARREN, M. D., Professor of 
Anatomy and Surgery in Harvard Uni- 
versity, Boston. 

GEORGE B. WOOD, M. D., Professor of 
Materia Medica and Pharmacy in the Phi- 
ladelphia College of Pharmacy. 






PROSPECTUS. 



This work will present a digest of the existing state of knowledge 
in all the branches of the healing art; in special, regional, abnormal, 
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ABIRR.— ABORT. 



MM. Chevallier, Richard, et Guilleman, 
Diet, des Drogues. 
Dr. Geiger, Handbuch der Pharmacie. 

Geo. B. Wood. 

ABIRRITATION. (From ab, priv. and 
irritatio, irritation.) This term has been 
employed by Brotjssais and his s.chool, to 
denote a diminution of the vital phenomena 
in the different tissues. (See Irritation.) 

Bibliography. — Caignou et Quemoxt. Le- 
cons du Docieur Broussais sur les Phlegmasies 
Gasiriques. Paris, 1823. p. 7. 

Begin. Principcs Gtneranx de Physiologie 
Pathologique. Paris, 1828. p. 126. 

Broussais. Principles of Physiological Medi- 
cine. Trans, by Hays and Griffith, Philadelphia, 
1832. pp. 28 & 29. I. H. 

ABLACTATION. (From ab, priv. and 
lacto, I suckle.) The absence or cessation 
of lactation, (q. v.) This word, as origin- 
ally employed by the Latin writers, was 
synonymous with our term weaning, (q. v.); 
but it has been restricted by some modern 
♦ writers to this process as it r.elates to the 
mother. I. H. 

ABLATION. (From auferre, to re- 
move.) Formerly employed in a very ex- 
tensive signification, and expressed the 
subtraction of whatever was in excess, in 
the body ; the reduction of regimen ; and 
the diminution of the mass of blood, by 
bleeding, &c. Its meaning has been much 
restricted by the moderns ; and it is now 
principally used in surgery, as a generic 
term, expressive of all cases where a part 
is taken away. It includes two species, 
Amputation and Extirpation, (q. v.) 

I. H. 

ABORTION. Abortus, Aborsus, Af- 
fluxio, Lat. Au6%ourx, £%a*5?xo6i$, Hip. At- 
aq>9opa, fx^pco^ao?, Aristot. Avortement, Fr. 
Aborto, Ital. Falche Geburt, Fehlgeburt, 
Germ. Miscarriage, Eng. The prema- 
ture expulsion of the contents of the uterus 
after conception. 

Art. I. Abortion. (Obstetr.) The con- 
tents of the uterus maybe expelled, from the 
first few weeks after impregnation to the 
full period of utero-gestaticn. But the term 
Abortion, is usually confined to such cases 
of expulsion of the ovum, as happen before 
the fifth month ; after this period, to near 
, the full term, it is usual to call this acci- 
dent by the name of Premature Delivery, 
(q. V.) 

Causes. — Any thing capable of exciting 
uterine contraction to a certain degree, 
may be considered as a cause of abortion : 
these may be all mechanical violences; 
passions and emotions of the mind j sudden 



alarm ; drastic purgatives ; almost all the 
exanthemata, especially small-pox and 
scarlatina ; peculiar conditions of the ute- 
rus itself, or of its connexions with the 
vagina, as first made known to the public by 
Madame Boivin, though not first observed 
by her ; syphilitic taint ; a rheumatic con- 
dition of the uterus itself; local plethora; 
the death of the foetus, &c. 

Some of the causes just enumerated, for 
instance, mechanical violences, are per- 
haps the most common ; such are blows, 
falls, slips, over-exertion, &c. The next 
in frequency, are passions and emotions of 
the mind, alarms, &c. ; while the peculiar 
condition of the uterus, as regards its con- 
dition with the vagina, and other portions 
of the lower part of the pelvic cavity, and 
rheumatism, are the most rare — the former 
seldom or never occurring but with such 
women as have had many children, or such 
as have been maltreated during labour, or 
who have suffered numerous abortions ; the 
latter, only, perhaps, taking place from pre- 
mature exposure to cold after delivery or 
abortion. 

There is much diversity in the influence 
of the causes of abortion, owing, most 
probably, to a more or less healthfulness 
of the uterus itself. In some instances, 
the slightest of the enumerated causes will 
be followed by unappeasable contractions 
of the uterus ; while in others it requires 
that they should be applied with great force 
to produce similar consequences. 

Where organic derangements of the 
uterus exist, abortion takes place with 
great uniformity at a certain period of 
utero-gestation. In such cases, the uterus 
will not surfer distension beyond a certain 
degree, without being excited to contrac- 
tion ; because its organization is so de- 
ranged, as not to permit of distension 
without causing uterine contractions. The 
same eifect is pretty constantly observed 
in the rheumatic condition of this organ. 

Local plethora, in many instances, be- 
comes a cause of abortion: this is most 
frequently observed in women with whom 
abortion becomes a habit ; hence the fre- 
quency of this accident in certain females, 
even to the amount of a dozen consecutive 
times. This act readily establishes itself 
as a habit, because each time it takes place 
the uterus becomes the more readily dis- 
posed to plethora. That the foetus may 
become diseased and die in utero, even at 
an early period of gestation, is supported 
by many facts ; and when this is constitu- 
tional, as it sometimes is, the woman suf- 
fers abortion as certainly as impregnation 
takes place. 



90 



ABORTION. (Obstetr.) 



It has just been stated, that uterine con- 
traction is essential to the throwing off of 
the ovum ; and that the remote causes all 
tend, with more or less certainty, to pro- 
duce this effort of the uterus. If this be ad- 
mitted, there will be but little difficulty in 
explaining the symptoms that attend this 
accident. 

Symptoms. — It rarely happens that abor- 
tion, or the disposition of the uterus to cast 
off its contents, is not preceded by pretty 
uniform phenomena : as, more or less pain 
in the back and loins, with a sensation of 
bearing down; lassitude; depression of 
spirits; and a more than natural, disposi- 
tion to make water. These symptoms are 
generally sooner or later followed by a 
I* show," or a slight discharge of blood 
from the vagina, which will very soon, in 
some instances, amount to an hemorrhagy. 
Sometimes, and not very unfrequently, this 
"show" is the initial symptom; or, the 
aborting effort may commence by a sudden, 
and even an alarming discharge of blood ; 
this especially happens to such as have had 
frequent repetitions of this accident. 

The blood is expelled in coagula, or in 
a current, as the separation of the ovum is 
more or less extensive ; or as the point of 
separation may be more or less remote 
from the os uteri ; for a separation of the 
connecting medium of the ovum and ute- 
rus is a sine qua non to hemorrhage ; at 
least, until after, perhaps, the sixth month. 
For up to this period, or nearly to this time, 
the ovum is almost entirely attached to the 
internal parietes of the uterus by the de- 
cidua and decidua reflexa, which subserves 
the offices of the placenta ; but beyond this 
period, so much of the transparent portion 
(the membranes) of the ovum is formed, 
as to line a considerable part of the ute- 
rus ; but from the detachment of which, 
no hemorrhage follows immediately, though 
eventually this separation may involve that 
of other portions, and thus produce a flood- 
ing of greater or less extent. 

A flooding, however, is not a uniform 
attendant upon abortion ; for the ovum is 
occasionally thrown off without this often- 
times alarming symptom; this, however, 
is confessedly rare, and perhaps only hap- 
pens where no union was formed between 
the ovum and the uterine cavity. 

Pain, like that of genuine labour, almost 
always accompanies abortion. At this we 
need not be surprised, as the action of the 
fundus and body of the uterus has to over- 
come the resistance of the neck of that 
organ, before the ovum can be expelled ; 
and this is sometimes only accomplished 
by long-continued and frequently-repeated 



uterine efforts, and these oftentimes of the 
most painful kind. 

At other times, this act is effected with 
very little suffering, or with a trifling ex- 
penditure of blood. This is more frequently 
the case with women who abort habitually. 

The mammae frequently sympathize with 
the uterus during the progress of abortion, 
or previously to its commencement. In 
the first instance, they become painful and 
a little swelled, if the process be slow and 
not very painful ; in the second, it happens 
from the loss of vitality of the embryo or 
foetus: when this takes place before any 
other symptom shows itself, it becomes the 
cause of uterine contraction ; as the ovum 
now, from its loss of life, constitutes an ex- 
traneous body within the uterine cavity. 
These cases are rarely attended by as much 
pain, or by so great an expenditure of 
blood, as where abortion is suddenly pro- 
duced by other causes, and where the ovum 
maintains its vitality perhaps to almost the 
last moment. 

It is probable that the ovum has, been 
deprived of its vitality in all such cases of 
abortion, as are attended, or preceded, by 
diarrhoea ; and that those who have enu- 
merated this condition of the bowels among 
the causes of abortion, have mistaken an 
effect for a cause; for however strongly 
the sympathy between the rectum and 
uterus may be insisted on, it must as con- 
fidently be declared, that it is reciprocal ; 
and consequently, that the uterus, in such 
cases, may have been the original seat of 
irritation. This opinion is strengthened 
very often by the state of decay of the 
ovum at the time of its expulsion, but es- 
pecially by the previous condition of the 
mammse in such instances, as they are 
sure to have been tumid, and then to have 
become flaccid, before the escape of the 
ovum. 

Sometimes, the first threatening of abor- 
tion is the sudden jet, or escape, of the 
liquor amnii. This, however, is rare, until 
after the sixth month, though it occa- 
sionally happens as soon as the second 
month. Uterine contraction and hemor- 
rhage are sure to follow at no very distant 
period, and forbid success to any effort to 
prevent the expulsion of the other contents 
of the ovum. 

The degree of hemorrhage is not al- 
ways in the ratio of the advancement of 
gestation ; though generally speaking, un- 
der similar circumstances it may be laid 
down to be the case ; for the loss of blood, 
for the most part, is governed by the period 
of conception, the force of the remote 
cause, the degree or extent of detach- 



ABORTION. (Obstetr.) 



ment, the vigor of the general circulation, 
the period that elapses before uterine con- 
tractions can be successful in the expulsion 
of the ovum, and the state of the ovum, that 
is, whether it remains entire, or has been 
forced open so as to expend the liquor 
amnii. Nor is pain always an attendant 
upon abortion, as many cases have occur- 
red without it, though uterine, contractions 
must take place. 

Diagnosis. — The only complaint with 
which abortion can be confounded, is ame- 
norrhea when about to be relieved; but 
there is no very great difficulty in ascer- 
taining the true nature of the pain and 
discharge of blood, especially in the mar- 
ried woman. 

The married woman is rarely liable to 
suppression of the menses, without its hav- 
ing been preceded, by some pretty evident 
cause, as exposure to cold or wet, or some 
chronic disease, especially phthisis pulmo- 
nalis ; or it may happen at that period of 
life at which the menses are preparing to 
take their final leave. When the first of 
these causes has produced the suppression, 
the married woman suspects herself to be 
pregnant, if she pass the common men- 
strual period, without bearing in mind at 
the moment, that she has exposed herself 
to any but the common or natural cause 
for this interruption. In these cases, na- 
ture very frequently overcomes the diffi- 
culty, after the obstruction has existed for 
two or three periods. The reappearance 
of the catamenia may now be mistaken for 
a threatening abortion; and the woman 
gives so effectually into the belief herself, 
that she immediately takes every precau- 
tion to prevent it. 

In this case, for the most part, there has 
been none of the remote causes operating 
to produce abortion ; though this would not 
with certainty betray the exact nature of 
the discharge, as abortion often takes place 
without any evident cause. The discharge, 
however, is not exactly alike in both in- 
stances. In abortion, we almost always have 
coagula expelled : not so, when it is merely 
the catamenial discharge. In abortion, the 
discharge is generally more suddenly abun- 
dant, and may be repeatedly arrested for a 
short time ; whereas, in the menstrual eva- 
cuation, it is pretty uniformly continuous. 
Abortion is most frequently attended by 
alternate pains, which gradually augment, 
both in force and frequency : this rarely 
happens with the catamenia; for should 
the patient have pain, as in dysmenorrhea, 
it gradually abates in its intensity, espe- 
cially alter the expulsion of a coagulum, 



91 

or of a membranous substance ; and if the 
woman have been subject to this form of 
menstruation, there is much less reason to 
suspect pregnancy ; and consequently, we 
may doubt that she is about to miscarry. 

In pregnancy, other signs present them- 
selves beside the mere arrest of the men- 
strual discharge: such is morning sickness, 
increase of the abdomen, enlargement and 
tenderness of the mamma?, &c. 

But after the third month, an examina- 
tion per vaginam will almost always dispel 
the doubt, should any exist, especially if 
the flooding be attended by pretty severe 
and long-continued pain. This examina- 
tion should never be omitted in cases of 
doubt, or where the symptoms have been of 
long continuance, as it will not only lead to 
a knowledge of the true nature of the com- 
plaint, but will furnish important indica- 
tions; for if the mouth of the uterus remain 
undisturbed, it will encourage attempts to 
preserve the ovum ; but on the other hand, 
if it be distended, or open, it will declare the 
insufficiency of every attempt to save the 
ovum. The difficulty in distinguishing the 
two conditions of the uterus, will diminish 
in proportion to the supposed advancement 
of pregnancy. 

Prognosis. — The prognosis in abortion, 
will always depend upon the extent of the 
hemorrhage that may attend the process ; 
and consequently will not differ from any 
other extensive loss of blood from the ute- 
rus, or even from other portions of the 
body. 

Treatment — The treatment of abortion 
will necessarily divide itself into general 
and local ; and the indications must be 
taken from the immediate condition and 
habits of the patient ; and will consist of 
attempts to prevent or subdue uterine con- 
traction, and abate hemorrhage. 

As uterine contraction must necessarily 
precede hemorrhage, the endeavour should 
be to interrupt, or overcome, the action of 
the uterus as early as possible, by rest in 
a horizontal position, by blood-letting, by 
opiates, a strict antiphlogistic regimen, and 
certain astringents. 

1. Rest. This is essential to the suc- 
cessful treatment of threatened abortion ; 
therefore, when a pregnant woman is ex- 
posed to either of the remote causes enu- 
merated above, and this of sufficient force 
to excite anxiety for the welfare of the 
patient, she should be immediately cau- 
tioned against every circumstance that 
may tend to aid the operation of this cause, 
and be ordered to her bed, that the system 
may become tranquillized by a supine posi- 



92 



ABORTION. (Obstetr.) 



tion and perfect rest This, however, may 
not always be sufficient of itself to inter- 
cept or subdue uterine contraction ; it may 
therefore require the abstraction of blood 
from the arm as early as may be judged 
expedient. 

2. Blood-letting, It rarely happens that 
this remedy can be dispensed with in habits 
disposed to be plethoric, and is often of 
singular benefit in opposite temperaments, 
when arterial action is roused beyond the 
healthy bounds ; the loss, therefore, of a 
few ounces of blood is absolutely necessary, 
when there is a painful aching in the back, 
a heaviness about the loins, a sense of 
weight or bearing down, even without 
pain, but especially when there is pain, 
and when there may be a "show" from 
the vagina. The loss of eight or ten ounces 
of blood from the arm, and a strictly anti- 
phlogistic regimen, will not only tend to 
tranquillize the circulating system, but 
will prepare the way for the employment 
of opiates. 

3. Opiates. Opium, in some form or 
other, is oftentimes of the highest conse- 
quence, and should never be omitted after 
the system is properly prepared for it by 
rest, and, if necessary, by blood-letting. 
Much judgment is, however, required for 
its exhibition, that it may not do injury. 
It should never be given whew the pulse 
is highly excited, or when its operation is 
habitually unfriendly to the system. In 
the first instance, it should be preceded by 
rest and the loss of blood ; in the second, 
the Ext. Hyosciam. may be substituted with 
much ad vantage. In such cases this remedy 
should be given in proper quantities to calm 
the system ; and it must be repeated in suf- 
ficient doses, and at proper intervals, to 
overcome uterine contraction. It may be 
administered by the mouth ; or by the rec- 
tum, in the form of injection, or suppository. 

The use, however, of opium has its limit; 
for it must not be persevered in after it is 
ascertained that it would be neither useful 
nor practicable, to subdue uterine contrac- 
tion ; and this must be ascertained by an 
examination per vaginam, as recommended 
above, and if the os uteri be found open, 
or the neck distended, it would be hurtful 
to persevere with the opium ; or when 
the mammae have become suddenly flaccid, 
after having been distended and painful, 
it would be found equally useless ; for in 
this instance, the embryo, or foetus, has 
certainly lost its life, and it would be mis- 
chievous to interrupt pains, as it is by 
their agency alone that the lifeless ovum 
can be expelled; and the quicker this is 



done, the better for the safety of the 
mother. 

4. Regimen. It would, in many in- 
stances, be altogether unavailing to at- 
tempt preventing abortion by the means 
above suggested, if they were not aided by 
a proper diet. This is too commonly sup- 
posed to be a matter of no moment in the 
treatmenfof abortion ; but this is an error 
of great magnitude, and it should not be 
lost sight of that it is so. None other than 
the blandest vegetable substances should 
be given, and these without any seasoning ; 
therefore, every species of liquor, or even 
spices, should be prohibited, during the 
active, or commencing stage of abortion. 
Water, toast-water, barley-water, gum- 
water, or weak lemonade, should alone be 
given as drinks ; and even these should be 
administered with a proper regard to the 
rest, or absence of motion, of the patient. 

5. Certain astringents. The* astringents 
most to be relied upon are the acetate of 
lead, the extract of rathany, and red rose- 
leaf tea. The acetate of lead may be giv- 
en in doses of two to six grains, every 
hour or two, guarded by opium, as the 
hemorrhage may be more or less alarm- 
ing. If it offend the stomach, it can be 
given per anum in form of an injection. 
Twenty grains of the acetate, sixty drops 
of laudanum, and two or three ounces of 
water, will be the proper proportions. Six 
or eight grains of the extract of rathany 
may be given every hour or two, drinking 
after it a wine-glass full of red rose-leaf 
tea, made as follows ; half an ounce of the 
leaves must have a pint of boiling water 
poured on them and allowed to stand — 
strain off a wine-glass full, as wanted — it 
may be sweetened, if preferred. If there 
be pain when the rathany is exhibited, it 
will be proper to aid' it by opium, as above 
directed. 

Local treatment This only becomes 
necessary when an hemorrhage is pres- 
ent ; and as this will differ in degree, it 
will require remedies proportionate to its 
extent. These applications will consist of 
cold water, vinegar, or brandy ; the tam- 
pon, and the crotchet. 

The cold wet applications are placed 
upon the lower part of the abdomen and 
vulva — their coldr.ess may be increased, if 
desirable, by the addition of ice. These 
appliances are oftentimes highly useful, 
but must not be carried too far — that is, to 
the prostration of the system ; therefore, 
when the pulse becomes feeble, concen- 
trated, and frequent, the cold remedies 
should be desisted from, and not repeated 



ABORTION. (Obstetr.) 



1 



until the system shows a disposition to re- 
act. During this time, the feet and legs 
should be kept warm by artificial means. 
The tampon must be resorted to, as soon 
as the flooding becomes rather excessive 
— a piece of soft sponge of sufficient size 
is the best, and should be introduced into 
the vagina after lubricating it well with 
melted hog's lard ; it should not remain 
longer within the vagina than twelve 
hours without being changed. It must not 
be crammed into the passage with such 
strictness as to obstruct the flow of the 
urine ; and it should never be introduced 
into the neck of the uterus. This is cer- 
tainly the most efficacious means of ar- 
resting this kind of hemorrhage ; and its 
employment must not be too long delayed. 
The crotchet consists of a piece 
of steel of the thickness of a small 
quill at its handle, and gradually 
tapered off to its other extremity 
which is bent to a hook of small 
size. (See accompanying figure, 
which represents the instrument 
one third the natural size.) This 
instrument is highly useful in cases 
in which the flooding continues 
after the ovum has been broken 
and its contents expelled. A por- 
tion of the involucrum sometimes 
insinuates itself into the neck of 
the uterus, and prevents the degree 
of contraction necessary to inter- 
rupt farther bleeding. This ac- 
cident most frequently attends the 
earlier abortions. As hemorrhage 
is maintained by the cause just 
named, it suggests the propriety 
of never breaking the ovum ; espe- 
cially before the fourth month. 
When the flooding is maintained 
by this cause, it will not cease but 
upon the event of its removal. 
This condition of the placenta and 
neck of the uterus is easily ascer- 
tained by an examination ; it will 
readily be felt to be embraced by the neck 
of the uterus ; and though a portion may 
protrude a little distance below the os tincse, 
it cannot be extracted by the fingers ; for 
the os uteri or cavity of the uterus will not 
be sufficiently large to permit the fingers 
to pass into it, that this mass may be remov- 
ed ; the crotchet should then be substi- 
tuted ; the mode of using it is as follows : 
The fore finger of the right hand is placed 
within or at the edge of the os tincse ; 
with the left we conduct the hooked ex- 
tremity along this finger, until it is within 
the uterus ; it is gently carried up to the 
fundus, and then slowly drawn downwards, 



which makes its curved point fix in the 
placenta ; when thus engaged, it is gradu- 
ally withdrawn, and the placenta with it- 
In every case in which I have used it, the 
discharge has instantly ceased. 

Prophilaxis. It has been noticed above, 
that aborting frequently becomes habitual 
— and when it is so, it has been found very 
frequently difficult to interrupt it, unless 
very rigid and exact means be employed. 
The following plan will almost always 
succeed, if regularly pursued. 

1st. The patient must be confined to 
her bed, or preferably to a mattress, as 
quickly as practicable after she overruns a 
menstrual period. On this she must con- 
tent herself to remain, almost without mo- 
tion ; but certainly without exertion. 

2d. She must lose, by leeches or cup- 
ping, about four or five ounces of blood, 
from the inner side of the thigh, four or 
five inches above the knee, the week pre- 
viously to the next menstrual period ; and 
this operation must be repeated, again and 
again, at the respective periods — or in 
other words, every four weeks. 

3d. The bowels should be kept well 
regulated, by medicine of the mildest kind, 
as castor oil, magnesia, Seidlitz powders, 
&c., but purging must be avoided. 

4th. She must be kept as strictly upon 
a milk and vegetable diet, as the condition 
of the stomach will permit. 

5th. Sexual intercourse should be strict- 
ly prohibited. 

6th. This plan must be persevered in 
for at least two months after the period at 
which the patient was usually wont to 
miscarry. 

7th. Blisters to the abdomen or sacrum 
have occasionally been found useful in in- 
terrupting the aborting habit. They are, 
however, not only inconvenient, but some- 
times very troublesome, without proving 
effectual ; they should therefore be looked 
upon as a dernier resource. We recom- 
mended their use more than twenty years 
ago. (See Amer. Edit, of Rees* Cyclop. 
Art. Abortion.) They have since been re- 
commended by Dr. Jackson, of Northum- 
berland, and others. (See Bibliography to 
this article.) We have not, however, had 
recourse to them for some years past, for 
the reasons above stated, and from having 
found, in a great number of cases, the plan 
just laid down, to be attended with the 
most entire success. 

Wm. P. Dewees. 

Bibliography. — Albinus. Diss, de aborfu. 
Franc. 1699. in 4to. 

Stahl. Diss, de abortu et foetu mortuo. Halae, 
1704. 4to. 



94 



ABORTION. (Med. Leg.) 



Born. De abortu salubri. Lipsise, 1717. 4to. 

Stoll. De abortu, in Diss. Med. edit. Eererel. 
T. IV. 

Dethardixg. De Foetus immaturi exclusions 
Boetoch. 1748. 

Jasserini. De abortu. Vien. 1777. 

Giiuner. De abortivis. Jena, 1799. 4to. 

Mayer, Aphorismi de causis abortum provo- 
cantibus. Francf. 1780. 4to. 

Waloschmtdt. De abortus fact i signis, &c. 
Kilon. r.23. 

Becker. De abortu. Got. 1798. 4to. 

Gregorini. Dehudrope uteri et hudatidibus. 
Halae, 1795. 

Siebold. Von den Friihgeburten in dessen 
Handb. zur Erkenntnisz vnd Heiluiig der Frau- 
enzi miner Krankheiten. Frank. 1823. 

Siebold. Art. Abortus. Encyclopiidisches 
worterbuch der Med. Wissens. Berlin, 1828. 

Le Roy. Lecons sur les pertes de sang pen- 
dant la grossesse et sur lesfausses couches. Paris, 
1801. 

St. Germain. Traite des fausses couches. Pa- 
ris, 1655. 

Redmax. Diss, de abortu. Lugd. Bat. 1748. 

Pexsexs. Diss, sur Vavoriement. Paris, an. 
XIII. 4to. 

Duges. Sur les causes de Vavoriement. Revue 
Med. for 1824. Tom. III. p. 74. Ibid. Manuel 
des accouchemens. Paris, 1830. 

Audry. Sur les maladies du feet us et ses an- 
nexes. Journ. des Progres. Paris, 1830. I. 126. 

Boivix. Recherches sur une des causes les plus 
frequences et les moins connues de Vavortement. 
Paris, 1828. 

Gardiex. Art. Avortement. Diet, des Sc. 
Med. Paris, 1812. Tom. II. 

Desormeaux. De abortu. (These de concours.) 
Paris, 1811. Ibid. Art. Avortement. Diet, de 
Med. Paris, 1821. T. III. 

Duges. Art. Avortement. Diet, de Med. et 
de Chir. prat. Paris, 1829. T. III. 

Velpeau. Flemeniar]) treatise on midwifery. 
Translated by C. D. Meigs, M. D. Philad. 183] . 
p. 229. 

J. Burxs. Obs. on abortion. London, 1806. 8vo. 
Ibid. Principles of Midw. with notes by Prof. 
James. New- York, 1831. 

Stewart. On the causes which destroy the 
foetus in utero. Med. Chirurg. Trans. V. 144. 

Dexmax. An introduction to the Tract, of 
Midwifery. With notes and emendations by J. 
W. Francis. New-York, 1829. p. 540. 

Ra.msbotiiam. Pract. Obs. in Midwifery. Lon- 
don, 1632. p. 357. 

Ryan. Manual of Midwifery. 3d Ed. Lon- 
don, 1631. p. 462. 

Gooch. Pract. compend. of Midwifery, &c. 
prepared for publication by G. Skinner. Phila- 
delphia, reprint, 1832. 

S. Bard. Compendium of Midwifery. 5th Ed. 
New- York, 1819. 

Bat delocque. Midviifery abridged. With 
notes by W. P. Dewees, M. D. Philad. 1823. 

W. P. Dewees. A treatise on the diseases of 
females. 4th Ed. 1833. 

E. Hale. Obs. on abortion. Med. Disserta- 
tions, read at the annual meetings of Massachu- 
setts Med. Assoc. Boston, 1829. Vol. IV. p. 357. 

L. Beldex. Observations on the utility of con- 
tinued venesection in the prevention of habitual 
abortum. New- York Med. and Phys. Journ. for 
April, 1829. p. 30. 

J. J. Graves. Remarks on the increase of still- 
born children and abortions. New- York Med. 
and Phys. Journ. for April, 1829. p. 37. 



S. Jackson, of Northumberland. On the use 
of blisters in threatening abortion, &c. Am. Journ. 
of Med. Sc Philad. 1828. Vol. II. p. 299. 

A. II. Cexas. Case of threatened abortion ar- 
rested by a blister to sacrum. Same Journal. Vol. 
V. p. 547. 

R. L. Fearx. Case in which abortion was pre- 
vented. North Am. Med. and Surg. Journ. 
Philad. 1831. Vol. XL p. 251. 

I. H. 

Abortion. (Medico-legal.) When judi- 
cial investigations are instituted in eases 
of real or suspected abortion, the principal 
points on which the medical witness will 
be examined, are, 1st. Has abortion really 
taken place] 2d. if so, was it the effect of 
natural causes, or was it artificially and 
intentionally produced ? 

1. Has abortion really taken place ? — 
This is to be ascertained by a careful ex- 
amination of the product of the premature 
labour, and of the female who is said to 
have, aborted ; and the chain of evidence 
will necessarily be defective if either of 
these examinations be neglected. 

Examination of the embryon. To ren- 
der this satisfactory, the changes that the 
embryon undergoes from the period of con- 
ception to the end of the ninth month, 
must be borne in mind. During the first 
weeks, the embryon being exceedingly 
small, may be confounded with a mole, a 
coagulum of blood, &e. The substances 
which are said to have been expelled from 
the womb must therefore be carefully ex- 
amined, by being washed in clear water, 
taking care not to injure them by com- 
pression or otherwise. If they be com- 
posed of a coagulum only, this will be dis- 
solved for the most part, leaving only the 
fibrine. If the expelled substance be a 
mole, it may be recognized by its solid con- 
sistence and other peculiar characters. 
(See Mole.) But if a foetus be present, it 
will present certain signs of organization 
which are more or less striking, according 
to the age of the embryon. 

Until the fifteenth day after conception, 
the uterus contains only the rudiments of 
the ovum, no part of the future embryon 
being distinguishable. At this period, how- 
ever, Meckel states that the ovum is six 
or eight lines in diameter, containing an 
embryon whose form has not unaptly been 
compared to that of a tadpole, and about 
three to four lines in length. At the end 
of the first month, the thorax and abdomen 
begin to appear in the form of round tu- 
bercles. At two months, the head is as 
large as half the body, the spine is formed, 
and the various parts of the face begin to 
be visible, whilst the extremities, although 
imperfectly formed, are readily distinguish- 



ABORTION. {Med. Leg.) 



95 



able ; and about the thirteenth week the 
sex may be determined. The embryon is 
now about two inches in length, and 
weighs rather more than an ounce. 

After this, no mistake can or ought to 
be made by the most inexperienced obste- 
trician. At the seventh month, the infant 
being so fully formed as to be capable, 
with certain precautions, of enjoying an 
independent existence, any questions that 
may arise belong rather to infanticide 
(q. v.) than to abortion. 

Examination of the woman. After hav- 
ing ascertained that the product examined 
was an embryon, and at what term of 
utero-gestation it had been expelled, the 
next point to be determined is the state 
of the mother ; and the value of this 
examination depends in a great measure 
on its being made at an early period, 
as well as on the period of utero-gesta- 
tion, at which the abortion has taken place. 
Actual inspection is of little use where 
more than a week has elapsed, as in that 
time the parts have so far regained their 
natural condition as to embarrass or even 
baffle inquiry. The period which has 
elapsed from conception has also much in- 
fluence, as the derangement of the parts 
consequent on the expulsion of the foetus, 
will, in most cases, be in a direct ratio to 
its age. But in every instance, if the abor- 
tion has occurred some time previous to 
the examination, and the woman has re- 
covered, the fact must be proved by cir- 
cumstantial evidence ; and the fact of the 
expulsion of the embryon, can only be in- 
ferred, from pregnancy having existed. It 
should also be borne in mind, that the ex- 
pulsion of moles, hydatids, <S;c, may in- 
duce the sanie appearance of the parts, as 
the passage of a foetus through them. It 
is therefore evident, that no legitimate de- 
duction can be drawn from the phenomena 
presented by the woman, however strong 
the presumption may be, without a concur- 
rence of the following circumstances. 

1. A certainty of the previous pregnan- 
cy, and comparison between the develop- 
ment of the foetus and the period of utero- 
gestation at which the abortion was said 
to have taken place. 2d. Such an advanced 
stage of pregnancy, as to produce, with 
the effects of the labour, certain well- 
known changes in the uterus and vagina. 
3. Finally, the examination having been 
made soon after the presumed abortion 
took place. 

2. Was the abortion the effect of natu- 
ral causes, or was it artificially produced ? 
Ih ascertaining this, concomitant or collat- 
eral circumstances should be allowed much 



weight ; as concealment of the pregnancy 
and an application for medical aid withou 
an acknowledgment of its existence ; the 
purchase and use of reputed abortives, 
&c. : and, on the other hand, of resort to 
professional assistance when miscarriage 
was expected, and the fact of the occur- 
rence of any event capable of producing 
premature labour. 

As the natural causes whi^h may in- 
duce abortion have been already fully ex- 
plained, it is unnecessary to advert to 
them in this place. The methods employed 
in order to excite the expulsion of the em- 
bryon, may be referred to two general 
heads; those which act through the gene- 
ral system of the parent, and those which 
are applied immediately to the uterus and 
its appendages. To the first class belong 
emetics, cathartics, and emmenagogues ; 
and to the latter, the application of leeches 
to the vulva, and mechanical violence. 

With regard to the first class, it should 
be remembered, that certain drugs are gen- 
erally supposed to be endowed with the 
power of causing the expulsion of a foetus, 
and although it is now generally admitted 
by practitioners that there are no abortives 
strictly speaking, the circumstance of the 
purchase and administration of one or 
more of these articles ought to be allowed 
an important bearing on the case. There 
is no doubt, however, that emetics, purga- 
tives, &c, are capable of producing abor- 
tion, particularly in females predisposed to 
it ; but there is no one article, the result 
of whose internal administration, is abor- 
tion and nothing but abortion ; the life of 
the mother is always endangered. There 
is no drug, says Dr. Male, which will pro- 
duce miscarriage in women who are not 
predisposed to it, without acting violently 
on their system, and probably endangering 
their lives ; and in this opinion he is up- 
held by almost every medical authority of 
any note. 

The abortive means which act directly 
on the womb and its appendages or con- 
tents, are much more certain in their ef- 
fects, but at the same time are more dan- 
gerous to the female. They consist in the 
application of mechanical irritation to the 
uterus and its contents, by the actual in- 
troduction of some instrument, the injec- 
tion of acrid substances into the vagina, or 
the employment of such external violence 
as will irritate or injure the uterus. As 
respects bleeding from the foot, and the 
application of leeches to the vulva, though 
sometimes resorted to for the purpose of 
producing abortion, they seldom or never 
will cause this phenomenon, without be- 



96 



ABORTIVES. 



ing pushed so far as to reduce the female 
to a dangerous state of debility ; in fact* 
when used moderately, they will in cer- 
tain cases avert this event. 

When a physician, or practitioner of 
midwifery, is called upon as a witness in 
cases of suspected abortion, his duty is to 
verify the fact of the abortion having 
taken place ; and, when he has satisfied 
himself that this was the case, to inquire 
into all the circumstances which preceded, 
accompanied, and followed this event : thus 
he is to examine whether it might not 
have been induced by natural or accidental 
causes ; what was the term of utero-ges- 
tation ; if, from the existence of some con- 
comitant disease, the woman had freely 
employed reputed abortives ; and, in short, 
to make every inquiry that may tend to 
elucidate the real cause of the event. On 
the other hand, it is also his duty to the 
laws, scrupulously to weigh every circum- 
stance which may tend to show that the 
abortion was premeditated on the part of 
the female or others. Hence, he is to as- 
certain whether the pregnancy was con- 
cealed, whether reputed abortive, drugs 
were administered, whether she w T as soli- 
citous to learn how abortion could be pro- 
duced, &c. The foetus and its envelopes 
should also be carefully examined, to dis- 
cover whether they bear any marks of an 
instrument having been used ; and in case 
of the death of the woman, a careful in- 
spection of the uterus and its appendages 
should be made, with the same intent. 

Laws in relation to abortion. The 
legislative enactments in the United States, 
respecting abortion, differ greatly from 
each other, whilst in some, the common 
law of England, as it stood at the Declara- 
tion of Independence, is still the rule of 
action. The English law, as stated by 
Blackstone, is : " If a woman is quick with 
child, and by a potion or otherwise killeth 
it in her womb, or if any one beat her, 
whereby the child dieth in her body, and 
she is delivered of a dead child, this, 
though not murder, was by the ancient 
law, homicide. But the modern law doth 
not look upon this offence in quite so atro- 
cious a light, but merely as a heinous mis- 
demeanour." This, being common law, is 
therefore in force in such of the United 
States as have no special legislative enact- 
ment on the subject. The law of England 
now in force under the act of 1803, being 
statute and not common law, has no force 
here. 

By the revised statutes of New- York, 
"Every person who shall wilfully admin- 
zster to any pregnant w T oman, any medi- 



cine, drug, substance, or thing, whatso- 
ever ; or shall use or employ any instru- 
ment or means whatever, with intent 1 
thereby to procure the miscarriage of any 
such woman, unless the same shall be ne- • 
cessary to preserve the life of such wo- 
man, or shall have been advised by two 
physicians to be necessary for that pur- 
pose ;" shall, upon conviction, be punished 
by imprisonment or fine, or both. 

The law in Louisiana is very full and 
explicit, condemning any person who pro- \ 
cures or is privy to the procurement of \ 
abortion, to imprisonment, unless it is pro- 
cured by medical advice for the purpose 
of saving the life of the mother. If death 
ensues from attempts to procure unlawful 
abortion, it is murder. 

In Connecticut, it is imprisonment for 
life, or such other less term as the court 
may award. It is evident that where ex- 
press provision to the contrary has not 
been made, the medical practitioner is 
placed in a disagreeable predicament. To 
save the life of the mother he is often 
called upon to produce abortion, and yet in 
all these cases he is criminal in the eye of 
the law, strictly speaking. At the same*, 
time, it is highly improbable that suchV 
cases will ever become the subject of judi-1 
cial investigation; but still, w T hilst the law; 
thus views him m the light of a felon, no 
obstetrician should rely on his own judg- 
ment alone, in cases thus involving the 
necessity of the destruction of the foetus, i 
and the possibility of a fatal result to the 
mother. 

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I. Briand. Manuel complet de Midecine ttgdle 
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J. Capuron. Mtdecine legale relative a Vart 
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R. E. Griffith. 

ABORTIVES. This term has been ap- 
plied to a class of remedies which were 
supposed to act in a special manner on the 
gravid uterus, causing an expulsion of its 
contents. The whole of them, with the 
exception, perhaps, of Ergot, act by their 



